Massage Therapist's Guide To Pathology & Clinical Massage Therapy Understanding, Assessing and Treating Over 70 Conditions

Massage Therapist’s Guide to Pathology
&
Clinical Massage Therapy Understanding, Assessing and Treating Over 70 Conditions
Definition Complications Treatment
- … - … -
Demographics Signs and Symptoms Medications
- … - … -
Etiology Massage Therapy Implications
- … Risks:
Benefits:
Options:
CMTO
Common Clinical Conditions with multi- Stages of Life: Neurological Conditions: Orthopedic Conditions: Post-surgical Conditions: Systemic Conditions:
Conditions that present factorial considerations:
as variables of:
- Stress - Inflammation - Pregnancy - Conditions of the - Conditions of the bone and periosteum - Conditions involving - Conditions of the cardiovascular system
central nervous system orthopedic interventions
- Pain - Infection - Infancy and - Conditions of the muscles and tendons - Conditions of the digestive system
childhood - Conditions of the - Conditions involve
- Mood - Scarring - Conditions of the fascia - Conditions of the endocrine system
peripheral nervous artificial openings
- Adolescence
- Anxiety - Swelling system - Conditions of the sin and connective tissue - Conditions of the gastrointestinal system
- Conditions involving
- Adulthood
- Sleep - Congestion - General neurological - Conditions of the synovial joints, cartilage, implants - Conditions of the immune system
- Senior years conditions ligaments and bursa
- Cognition - Movement - Conditions of the integumentary system
restriction - End of life - Systemic myofascial and orthopedic conditions
- Conditions of the lymphatic system
- Malignancy
- Conditions of the reproductive system
- Trauma and abused
- Conditions of the respirator system
- Conditions of the urinary system
School
Treatments 1 Treatments 2
- Inflammation - Whiplash - Sciatica
- Tissue Repair/Scar Tissue - Torticollis - Piriformis Syndrome
- Stress - Temporomandibular Joint Dysfunction - Thoracic Outlet Syndrome
- Depression - Adhesive Capsulitis - Cerebral Palsy
- Anxiety - Dislocation 7 Subluxation - Tension Headache & Migraines
- General adaptation syndrome - Pregnancy - Meniere Disease
- Tension Headache - Dupuytren’s Contracture - Chronic Congestive Heart Failure
- Strains - Patellofemoral Syndrome - Hypertension
- Contusions - Periostitis and Compartment Syndrome - Varicose Veins
- Edema / Lymphedema - Plantar Fasciitis - Thrombophlebitis & Deep Vein Thrombosis
- Hypertension - Pes Plan, Pes Cavus, Claw and Hammer Toes - Raynaud’s Disease/Phenomenon
- Osteoarthritis - Hyperlordosis – Spondylolisthesis and Spondylosis - Post Stroke
- Fibromyalgia - Hyperkyphosis – Scheurermann’s Disease - Post Heart Attack
- Muscle Spasm - Scoliosis - Chronic Bronchitis
- Tendinitis - Degenerative Disc Disease - Asthma
- Sprains - Infant Massage - Emphysema
- Rheumatoid Arthritis - Diabetes - Cystic Fibrosis
- Ankylosing Spondylitis - Amyotrophic Lateral Sclerosis - Sinusitis (Chronic Rhinitis)
- Other Inflammatory arthritides - Constipation - Amputation
- Osteoporosis - Irritable Bowel Syndrome & Inflammatory Bowel Disease - Trauma & Post-Traumatic Stress Disorder
- Gout - Polio - Addictions
- Bursitis - Parkinsons - Lyme Disease
- Fractures - Multiple Sclerosis & Trigeminal Neuralgia - Chronic Pain Syndrome
- Repetitive Strain Injuries - Bell’s Palsy - Prolonged Illness Hospitalization
- Wound Healing - Traumatic Brain Injuries & Crush and Severance Injuries to the Spinal Cord, - HIV/AIDS
Spinal Cord Injury
- Scar Resolution - Cancer
- Median, Radial & Ulnar Injuries
- Breast Massage
- Carpal Tunnel Syndrome
Contents
Integumentary System...............................................................................................3 Myofascial Pain Syndrome...............................................................................23 Sleep Disorders................................................................................................59
Contagious Skin Disorders......................................................................................3 Thoracic Outlet Syndrome................................................................................23 Vestibular Balance Disorders............................................................................60
Animal Parasites.................................................................................................3 Sciatica.............................................................................................................25 Circulatory System Conditions.................................................................................60
Fungal Infections of the Skin..............................................................................3 Piriformis Syndrome.........................................................................................26 Blood Disorders....................................................................................................60
Herpes Simplex...................................................................................................3 Other Connective Tissue Disorders......................................................................28 Anemia.............................................................................................................60
Staphylococcal infections of the skin.................................................................3 Bunions............................................................................................................28 Embolism, thrombus & Thrombophlebitis, Deep Vein Thrombosis.................60
Streptococcal infections of the skin...................................................................4 Bursitis.............................................................................................................28 Hemophilia.......................................................................................................62
Warts..................................................................................................................4 Shin Splints.......................................................................................................29 Leukemia..........................................................................................................62
Noncontagious Inflammatory Skin Disorders.........................................................4 Tendinopathies................................................................................................29 Myeloma..........................................................................................................62
Acne rosacea......................................................................................................4 Whiplash..........................................................................................................29 Sickle Cell Disease............................................................................................63
Acne vulgaris......................................................................................................4 Polymyalgia Rheumatica..................................................................................31 Vascular Disorders................................................................................................63
Eczema, dermatitis.............................................................................................4 Torticollis..........................................................................................................31 Aneurysm.........................................................................................................63
Neoplastic Skin Disorders.......................................................................................4 Iliotibial Band Contracture & Iliotibial Band Friction Syndrome.......................32 Atherosclerosis.................................................................................................63
Seborrheic Keratosis (SK)...................................................................................4 Nervous System Conditions.....................................................................................32 Hypertension....................................................................................................64
Skin Cancer.........................................................................................................5 Chronic Degenerative Disorders...........................................................................32 Raynaud Syndrome & Disease..........................................................................64
Skin Injuries............................................................................................................5 Alzheimer disease............................................................................................32 Varicose Veins..................................................................................................65
Burns..................................................................................................................5 Amyotrophic Lateral Sclerosis..........................................................................33 Heart Conditions..................................................................................................66
Decubitus ulcers.................................................................................................6 Huntington Disease..........................................................................................33 Heart Attack.....................................................................................................66
Scar Tissue..........................................................................................................6 Peripheral Neuropathy.....................................................................................34 Heart Failure (contain Chronic Congestive Heart Failure & Hypertension)......66
Musculoskeletal System Conditions...........................................................................7 Movement Disorders...........................................................................................34 Lymph and Immune System Conditions...................................................................68
Muscle Disorders....................................................................................................7 Dystonia...........................................................................................................34 Lymph System Conditions....................................................................................68
Muscular Dystrophy...........................................................................................7 Parkinson Disease............................................................................................34 Edema..............................................................................................................68
Spasms, cramps..................................................................................................7 Tremor.............................................................................................................36 Lymphangitis....................................................................................................69
Strains................................................................................................................7 Infectious Disorders.............................................................................................37 Lymphoma.......................................................................................................69
Bone Disorders.......................................................................................................9 Encephalitis......................................................................................................37 Mononucleosis.................................................................................................69
Osteosarcoma....................................................................................................9 Herpes zoster...................................................................................................37 Immune System Conditions.................................................................................69
Osgood-Schlatter disease...................................................................................9 Meningitis........................................................................................................37 Allergic Reactions.............................................................................................69
Osteoporosis......................................................................................................9 Polio, postpolio syndrome...............................................................................38 Chronic Fatigue Syndrome...............................................................................70
Postural deviations / Hyperkyphosis (contains Scheuermann’s Disease), Psychiatric Disorders............................................................................................39 Fever................................................................................................................70
Hyperlordosis (contains Spondylolisthesis and Spondylosis) & Scoliosis..........10 Addiction..........................................................................................................39 HIV/AIDS...........................................................................................................70
Joint Disorders.....................................................................................................12 Anxiety Disorders.............................................................................................39 Autoimmune Disorders........................................................................................72
Adhesive Capsulitis / Frozen Shoulder.............................................................12 Attention Deficit Hyperactivity Disorder..........................................................40 Ankylosing Spondylitis......................................................................................72
Baker Cysts.......................................................................................................13 Autism Spectrum Disorder...............................................................................40 Crohn Disease..................................................................................................73
Gout.................................................................................................................13 Bipolar Disorder...............................................................................................40 Lupus................................................................................................................73
Joint disruptions / Dislocation & Subluxation...................................................14 Depression.......................................................................................................40 Multiple Sclerosis.............................................................................................73
Joint replacement surgery................................................................................15 Eating Disorders...............................................................................................41 Psoriasis...........................................................................................................75
Lyme Disease....................................................................................................15 Obsessive-compulsive and related disorders...................................................41 Rheumatoid Arthritis........................................................................................76
Osteoarthritis...................................................................................................16 Trauma- and stressor-related Disorders...........................................................42 Scleroderma.....................................................................................................76
Patellofemoral Pain Syndrome.........................................................................16 Nervous System Injuries.......................................................................................42 Ulcerative Colitis..............................................................................................76
Spondylolisthesis..............................................................................................17 Bell Palsy..........................................................................................................42 Respiratory System Conditions................................................................................76
Spondylosis......................................................................................................17 Complex Regional Pain Syndrome....................................................................44 Infectious Respiratory Disorders..........................................................................76
Sprains..............................................................................................................18 Spinal Cord Injury.............................................................................................44 Acute Bronchitis...............................................................................................76
Temporomandibular Joint Disorder.................................................................18 Stroke...............................................................................................................44 Common Cold...................................................................................................77
Fascial Disorders..................................................................................................19 Traumatic Brain Injury......................................................................................45 Influenza...........................................................................................................77
Periostitis & Compartment Syndrome.............................................................19 Trigeminal Neuralgia........................................................................................45 Pneumonia.......................................................................................................77
Dupuytren Contracture....................................................................................19 Crush and Severance Injuries to Spinal Cord....................................................46 Sinusitis / Chronic Rhinitis................................................................................77
Ganglion cysts..................................................................................................20 Median, Radial & Ulnar Injuries.......................................................................50 Tuberculosis.....................................................................................................78
Hammer toe.....................................................................................................20 Nervous System Birth Defects..............................................................................52 Chronic Obstructive Pulmonary Disease..............................................................79
Hernia...............................................................................................................20 Spina Bifida.......................................................................................................52 Chronic Bronchitis............................................................................................79
Morton Neuroma.............................................................................................20 Cerebral Palsy...................................................................................................52 Emphysema......................................................................................................81
Plantar fasciitis.................................................................................................20 Other Nervous System Conditions.......................................................................54 Other Respiratory Disorders................................................................................82
Pes Planus & Pes Cavus....................................................................................21 Fibromyalgia.....................................................................................................54 Asthma.............................................................................................................82
Neuromuscular Disorders....................................................................................21 Tension Headaches & Migraines......................................................................55 Cystic Fibrosis...................................................................................................84
Carpal Tunnel Syndrome..................................................................................21 Meniere Disease...............................................................................................58 Laryngeal Cancer..............................................................................................84
Disc Disease & Degenerative Disc Disease.......................................................23 Seizure Disorders.............................................................................................59 Lung Cancer......................................................................................................84
Digestive System Conditions....................................................................................84 Endocrine System Conditions...................................................................................93 Uterine Cancer...............................................................................................100
Disorders of the Upper Gastrointestinal Tract.....................................................84 Diabetes Mellitus.............................................................................................93 Disorders of Other Female Reproductive Structures..........................................101
Celiac Disease...................................................................................................85 Hyperthyroidism..............................................................................................96 Breast Cancer.................................................................................................101
Esophageal Cancer...........................................................................................85 Hypothyroidism................................................................................................96 Ovarian Cancer...............................................................................................101
Gastroenteritis.................................................................................................85 Metabolic Syndrome........................................................................................96 Ovarian Cysts..................................................................................................102
Gastroesophageal Reflex Disorder...................................................................86 Thyroid Cancer.................................................................................................96 Disorders of the Male Reproductive System......................................................102
Peptic Ulcers....................................................................................................86 Urinary System Conditions.......................................................................................96 Benign Prostatic Hyperplasia..........................................................................102
Stomach Cancer...............................................................................................87 Kidney Disorders..................................................................................................96 Prostate Cancer..............................................................................................102
Disorders of the Large Intestine...........................................................................87 Kidney Stones...................................................................................................96 Prostatitis.......................................................................................................103
Colorectal Cancer.............................................................................................87 Polycystic Kidney Disease.................................................................................96 Testicular Cancer............................................................................................103
Diverticular Disease..........................................................................................88 Pyelonephritis..................................................................................................97 Other Reproductive System Conditions.............................................................103
Irritable Bowel Syndrome.................................................................................88 Renal Cancer....................................................................................................97 Menopause....................................................................................................103
Disorders of the Accessory Organs.......................................................................89 Renal Failure....................................................................................................97 Pregnancy.......................................................................................................104
Cirrhosis...........................................................................................................89 Bladder and Urinary Tract Disorders....................................................................98 Pre-menstrual Syndrome...............................................................................108
Gallstones.........................................................................................................89 Bladder Cancer.................................................................................................98 Sexually Transmitted Infections.....................................................................108
Hepatitis...........................................................................................................90 Interstitial cystitis.............................................................................................98 Principles of Cancer................................................................................................108
Liver Cancer......................................................................................................91 Urinary Tract Infection.....................................................................................98 Other Conditions....................................................................................................112
Pancreatic Cancer.............................................................................................91 Reproductive System Conditions.............................................................................99 Infant Massage  Handout...........................................................................112
Pancreatitis......................................................................................................91 Disorders of the Uterus........................................................................................99 Amputation handout......................................................................................113
Other Digestive System Conditions......................................................................92 Cervical Cancer.................................................................................................99 Breast Massage handout................................................................................114
Candidiasis.......................................................................................................92 Dysmenorrhea..................................................................................................99
Inflammatory Bowel Disease............................................................................92 Endometriosis................................................................................................100
Constipation.....................................................................................................92 Fibroid Tumors...............................................................................................100
Integumentary System
Contagious Skin Disorders
Animal Parasites
Head lice, crab lice (pubic lice), body lice, scabies mites
Fungal Infections of the Skin
Fungal Infections
Definition Tinea corporis Signs and Symptoms
- Superficial infection of the skin with fungi - “body ringworm” (NO WORMS!) - Characteristic lesion: slowly enlarging reddish scaly circle, paler
 AKA mycosis - Trunk, extremities in the middle
 Caused by dermatophytes - Scratching can spread it  (mushrooms grow in the same pattern)
 Lesions are tinea - Looks like expanding rings, healed in center -May also involve blisters, ulcerations, pus-filled sores, secondary
Demographics Tinea cruris bacterial infection
- Very common, especially in warm climates - AKA “jock itch” Treatment
- Athlete’s foot is especially common - More common in males than females - Topical or oral antifungal medication
- (brought to America by soldiers from WWI) - Associated with arm damp conditions and tight clothing - Lasers, photodynamic therapy, surgery if necessary for nails
Etiology - Spares the penis and the scrotum, may appear on the thighs - Keep skin dry, preventive measures
- Transmitted via touch and low back Medications
 Skin-to-skin Tinea pedis -Topical antifungal applications
 Skin-to-something - AKA athlete’s foot -Oral antifungal medications
- On a new host dermatophytes dissolve keratin, invade stratum - Usually begins between 3rd and 4th digits Massage Therapy Implications
corneum - Burns and itches, weeping blisters, risk of secondary infection Risks: don’t promote the spread of lesions; these are local
 Especially at skin folds - “moccasin distribution” is dry, not between the toes contraindications at least
 Create tinea lesions Tinea manuum Benefits: local, covered lesions allow massage for the rest of the
- Several types of fungi - Fungal infection on the hands, often from handling athlete’s body
Types of Fungal Infections foot Options: beware spreading athlete’s foot from one foot to another;
Tine capitus Onychomycosis consider working through the sheet
- Fungal infection of the scalp - Fungal infection under fingernails or toenails
- Mostly pre-adolescent children - AKA “tinea unguium”
- Can cause permanent hair loss - Destruction of the nail is oncholysis
Tinea versicolor
- Causative agent is different
 Normally benign organisms become aggressive
 Patches of hypo- or hyper- pigmented skin
 Not considered to be contagious
Herpes Simplex
Herpes Simplex
Definition Types of Herpes Simplex Eczema herpeticum
- HSV-1: viral infection around the mouth Oral herpes - Herpes develops with atopic dermatitis (a type of eczema)
- HSV-2: viral infection around the genitals - “herpes labialis” - Mostly in children
- Distinction is no longer considered important  Outbreaths with immune suppression, stress - Widespread outbreak
Etiology  Usually on lips, around mouth Ocular herpes
- Oral herpes is transmitted through oral or respiratory  Can be lifelong problem - Virus on the eyelid, conjunctiva, cornea
secretions Genital herpes - Repeated outbreaks can cause permanent scarring
- Genital herpes is transmitted through mucous membranes - Outbreaths with immune suppression, stress Signs and Symptoms
- 1st outbreak = primary  May be accompanied by fever, inflamed lymph nodes, - Prodrome stage: tingling, itching, pain
- Subsequent outbreaks = recurrent etc. - Blisters on a red base
- HSV is never fully expelled - Decreasing frequency over time  Virus-rich fluid in blisters
 Hides in DRG or trigeminal nerve - Can be on genitals, but also on -Scab over after 7-10 days
 Waits for trigger (drop in antibodies)  Thighs Treatment
 Cold, menstruation, stress…  Buttock - Nothing eradicates the virus
 “cold sore”, “fever blister”  Low back  Emphasis on prevention
 Reactivates at same area Herpes whitlow  Reducing frequency
- Possible complications: - Outbreak of lesions on hands, nailbeds  Staying healthy
 Risk of secondary bacterial infection - Used to be common among dental hygienists Medications
 Increased risk for HIV spread - Still happens when toddlers suck their thumbs -Antiviral medication to shorten outbreak
 Vaginal delivered babies at risk if genital herpes is  Example of autoinoculation -Topical cream for pain with oral herpes
present - Occupational hazard for massage therapists? -Prophylactic medication to reduce frequency of genital herpes
Communicability Herpes gladiatorum Massage Therapy Implications
- Skin-to-skin is easiest but… - On trunk, extremities Risks: active lesions contraindicate local massage; best to
 Virus is sturdy outside a host - Associated with wrestlers, other athletes with skin-to-skin reschedule if possible
 Can stay on surfaces for hours or days contact Benefits: no specific benefits; can improve quality of life and stress
- Autoinoculation is possible but not frequent - Blisters may rupture, look like ulcerations management
- In high concentration in blisters Herpetic sycosis Options: don’t work directly on the hands of a person with an
- May be present on skin during prodrome - Multiple lesions over the beard area active lesion
- (Your probably already have antibodies—you are protected)  Shaving with an active lesion—autoinoculation
Staphylococcal infections of the skin
Boils, folliculitis, methicillin-resistant, staphylococcus aureus (MRSA), hidradenitis suppurativa, pilonidal cysts
Streptococcal infections of the skin

Cellulitis, erysipelas (St. Anthony’s fire), necrotizing fasciitis
Warts
Warts
Definition Plane or flat warts Epidermodysplasia verruciformis
- Benign growths caused by HPV - Small, brown, smooth - Flat wart connected to genetic disease
- (not carried by toads) - In small groups, or hundreds  Suppressed immunity
Demographics - May spread with shaving - Risk of squamous cell carcinoma
- Mostly in children and teens Filiform warts Signs and Symptoms
- People who are immune-suppressed - AKA fascial warts - Depends on location, strain of HPV
Etiology - Fast-growing, thread-like - “Wart seeds” are tiny nearby capillaries
- HPV is a group of 100+ viruses associated with many types of - Eyelids, lips, neck - Don’t try to remove these; bleeding will spread the warts
warts - Painless Treatment
- This topic = non-genital cutaneous warts - Spread easily - Folklore/psychosomatic treatment
- Spread through direct or indirect contact Molluscum contagiosum - Garlic juice, duct tape
 Touching a wart, touching something with the virus on - Usually in children - Salicylic acid
it - NOT HPV - Cryotherapy (liquid nitrogen)
- Grow in areas that are frequently irritated - Can also be related to suppressed immunity, STI - Electrocauterization, lasers
- Grow slowly; no aggressive immune system response Genital warts - Oral or topical medications
- Can spread if area bleeds - Sexually transmitted infection Medications
Types of Warts - May trigger cervical cancer -Topical application of salicylic acid or other irritants
Common warts - Not the same HPVs as seen with common warts -Antiviral medications
- AKA verruca vulgaris Butchers’ warts -Antimitotic therapy (inhibits replication)
- Often on hands, knees, elbows - From handling meat Massage Therapy Implications
- Hard, flesh-colored growths - Look like common warts of hands (different virus) Risks: Local contraindication; cover warts of client or massage
Plantar Warts Focal epithelial hyperplasia therapist
- On sole of the foot - AKA Heck disease Benefits: no direct impact, but improved overall quality of life
- Loo like callus, but don’t try to clip or file them (that will spread - In mouth, lower lip, on tongue Options: Don’t irritate warts, but it is not necessary to omit the
them) - Mostly in Native Americans, Aleuts affected area altogether—incorporate it into the massage with
Cystic Warts light stroking or working through the sheet
- On sole of foot, but smooth, soft
- May express cheesy substance
Noncontagious Inflammatory Skin Disorders

Acne rosacea
Acne vulgaris
Eczema, dermatitis
Eczema and Dermatitis

Definition Seborrheic eczema Signs and Symptoms of Eczema
- Dermatitis: umbrella term for “skin inflammation” - In infants: “cradle cap” - Depends on type
 By convention: skin inflammation NOT due to infection - Yellowish, oily patches on skin folds around the head - Usually…
- 2 main issues: eczema, contact dermatitis - Very itchy  Redness
 Eczema: hypersensitivity reactions in the skin - May involve cutaneous yeasts  Itching
 Contact dermatitis: inflammation from externally Dyshidrosis  Risk of secondary infections
applied allergen or irritant - Fluid-filled itchy blisters Signs and Symptoms of Contact Dermatitis
Demographics - Mostly on hands and feet - Vary according to cause, length of exposure
- Most common version of eczema is atopic dermatitis - Seen with hot weather, stress - Range from extreme to very mild
 15% of all children - High risk of secondary infection Complications of Eczema and Dermatitis
 Most grow out of it Nummular eczema - Secondary bacterial or viral infection
 About 18 million in US - Small circular lesions  Staph, strep
Etiology - Legs and buttock  Eczema herpeticum
- Mostly due to hypersensitivity reactions - Can look like ringworm Use of steroid creams can damage the skin
- Type I and Type IV hypersensitivity reactions affect the skin - Men > women Treatment
 Eczema = type 1 reaction Factors in Contact Dermatitis - Identify triggers
 Often seen with other allergies – hay fever, asthma - Reaction to an allergen OR tissue irritant - Maintain hydration of skin (find a moisturizer that works)
 Allergic contact dermatitis = type IV reaction Types of Contact Dermatitis - Supplement essential fatty acids
 Delayed reaction Irritant contact dermatitis - Acupuncture works for some people
 Examples: poison ivy/oak, latex and nickel allergies - Result of skin damage - Various drugs
- Both made worse with itch-scratch cycle  Using a substance (harsh cleansers, etc.) that would Medications
 Susceptible to secondary infection damage anyone’s skin -Topical or oral steroidal anti-inflammatories
 Impetigo, herpes simplex, warts, etc.  Cessation of use relieves symptoms -Topical immunomodulators
Factors in Eczema Allergic contact dermatitis -Topical or oral antihistamines
- Fatty acid deficiency, compromises skin health - Immune response to trigger that isn’t dangerous -Antibiotics if necessary
- Excessive inflammatory responses - Common triggers include… Massage Therapy Implications
- Flares can be triggered by…  Nickle Risks: May make itching worse; be careful about lubricants; watch
- Rough textures, new detergents, etc.  Adhesive for open lesions
Types of Eczema  Dyes Benefits: Massage with a hypoallergenic lubricant may be very
Atopic dermatitis  Latex helpful if itching is not exacerbated
- Most common type of eczema  Urushiol Options: For compromised areas, use gloves or work through the
- Itchy, red, flaky, dry Other Types of Dermatitis sheet to “incorporate” the body
- Skin creases - Stasis dermatitis Research: Adverse events have been reported regarding skin
- Can cause lichenification  Usually lower legs of someone with poor circulation sensitivities in clients and in therapists
- Seen with asthma, hay fever - Neurodermatitis
 A small injury has a big inflammatory reaction
Neoplastic Skin Disorders

Seborrheic Keratosis (SK)
Skin Cancer
Skin Cancer – Basal Cell Carcinoma

Definition Types of Basal Cell Carcinoma Signs and Symptoms
- The most common form of skin cancer Nodular BCC - Classic sign of non-melanoma skin cancer:
- Slow-growing tumor of basal cells - Sometimes called “rodent ulcers”  A SORE THAT DOESN’T HEAL
- Usually on head or face - Pink, pearly edges, soft middle  A SORE THAT COMES AND GOES IN THE SAME PLACE
- Rarely metastasizes - Telangiectasias around the border - Can look like a flaky spot, a sac, a pimple, a mosquito bite…
- Can invade healthy tissues - May itch or bleed; not painful Treatment
Demographics Pigmented BCC - Usually surgically removed with no threat of metastasis
- Most common, least dangerous form of skin cancer - Dark lesions Massage Therapy Implications
- 80% of all skin cancer diagnoses in US - May be flat, brown, grey, bluish Risks: ignoring an important sign that should be investigated
 80% of 500,000 = 400,000 diagnoses - May look like melanoma Benefits: we can bring important things to our clients attention—
Etiology Superficial BCC with care for scope of practice and causing unnecessary alarm.
- As with all skin cancer types… - Looks like eczema or psoriasis Clients who have finished skin cancer treatment are good
 Mutation in skin cells - Loos like actinic keratosis (a type of SCC) candidates for massage
 Triggers: Micronodular BCC
 History of UV radiation (sunburns) - Multiple well-defined whitish lesions
 Genetics Morpheaform BCC
 Chronic skin inflammation or injury - Most serious
 Toxic exposures - Subtle on the surface; goes deep within
 Immunosuppressant drugs - Can invade muscle, bone, etc.
Skin Cancer – Squamous Cell Carcinoma
Definition Types of Squamous Cell Carcinoma Signs and Symptoms
- Cancer that develops in keratinocytes Actinic keratosis - Classic sign of non-melanoma skin cancer:
- Areas exposed to sunlight (also inside mouth) - AKA solar keratosis  A SORE THAT DOESN’T HEAL
- One type is associated with genital warts - Used to be considered pre-cancerous  A SORE THAT COMES AND GOES IN THE SAME PLACE
- Develops with long-term skin injury (boils, ulcers)  Most lesions become cancerous with time - Often appears on…
- Can metastasize  Now considered a type of BCC  Pre-existing injuries
Etiology - Brown or red scaly lesions on head and hands  Inside the mouth
- As with all skin cancer types… Actinic cheilitis  Areas with sun damage
 Mutation in skin cells - Form of actinic keratosis found on the lips Borders are less distinct than BCC lesions
 Triggers:  (can become aggressive with time) Treatment
 History of UV radiation (sunburns) Leukoplakia - Depends on stage, location
 Genetics - White, grey patches inside the mouth - Topical chemotherapy
 Chronic skin inflammation or injury  Tongue - Cryotherapy
 Toxic exposures  Cheek - Surgical excision
 Immunosuppressant drugs  Doesn’t scrape off Medications
- Associated with tobacco use -Topical chemotherapeutic agents
Bowen disease -Oral or injected chemotherapy
- “In situ SCC” -Photodynamic therapy (medication + light)
- Similar to actinic keratosis, but bigger Massage Therapy Implications
- Connection to HPV-16 Risks: Ignoring an important sign that should be investigated
Benefits: We can bring important things to our clients’ attention—
with care for scope of practice and causing unnecessary alarm.
Clients who have finished skin cancer treatment are good
candidates for massage
Skin Cancer - Malignant
Definition Types of Malignant Melanoma Signs and Symptoms
- Cancer that begins in the pigment cells that produce melanin Superficial spreading melanoma - May start as pre-existing mole that changes characteristics
(melanocytes) - Most common form  Becomes itchy
- Metastasizes readily - Spreads on the surface of the skin before invading deeply  Bleeds
 Liver, bones, CNS - Multicolored, maybe slightly elevated  Grows hair…
- Found on the skin, in the eye, reproductive tract, digestive tract Lentigo melanoma - A = Asymmetrical
- Good prognosis if found early, with shallow lesion - Begins as superficial discoloration in older people - B = Borders are indistinct
 < .07 mm deep - Pale, looks like “age spots” - C = Colors are mixed
- Poor prognosis if found late, with deep lesion - Lesions usually deeply notched, not purely oval - D = Diameter is large
 > 4 mm means metastasis is likely Acral lentiginous melanoma - E = Elevated (or evolving)
Demographics - As common in people of color as it is in Caucasians Treatment
- Least common, most dangerous type of skin cancer - Usually begins on an extremity - Depends on stage, location
- About 61,000 diagnoses/year  Under a fingernail or toenail is common  Topical chemotherapy
- About 10,000 deaths/year Nodular melanoma  Cryotherapy
Etiology - Most aggressive type  Surgical excision
- As with all skin cancer types… - Elevated from skin  Photodynamic therapy
 Mutation in skin cells - Penetrates deeper tissues  Biologic therapy
 Triggers: Uveal melanoma Medications
 History of UV radiation (sunburns) - Rare subtype -Topical or oral or IV chemotherapy
 Genetics - Affects the iris, ciliary body, choroid of the eye -Photodynamic therapy (medication + light)
 Chronic skin inflammation or injury - Impedes vision -Biologic therapy (drugs mimic cytokines to alter cell activity)
 Toxic exposures - Diagnosed by optometrist, ophthalmologist Massage Therapy Implications
 Immunosuppressant drugs Risks: ignoring an important sign that should be investigated
Benefits: We can bring important things to our clients’ attention—
with care for scope of practice and causing unnecessary alarm.
Clients who have finished skin cancer treatment are good
candidates for massage
Skin Injuries
Burns
Burns
Definition Complications Types of Burns Treatment
- Damage to the skin from… First Degree Burns - First and second degree: soothing lotion, antibiotic cream if
necessary
 Dry and wet heat - Mild, can be painful
- Third degree:
 Chemicals - Damage to superficial epidermis
 Wound cleaning
 Radiation - Non-blistering sunburn is an example
 Debridement
- Can also affect inner surfaces Second Degree Burns
 Skin grafts, plastic surgery
 Respiratory, digestive tracts - Partial thickness burn
Medications
Demographics - Goes deeper in the epidermis
-Antibiotic cream if necessary
- 1.1 million seek medical care each year in US - Blisters, risk of permanent scarring
-Analgesics for pain control
 50,000 hospitalizations Third Degree Burns
Massage Therapy Implications
 4,500 deaths from initial injuries - Full thickness burn
Risks: Acute burns contraindicate massage for pain, infection risk.
 10,000 deaths from infections - Penetrates to the dermis and deeper
Healed burns may have sensory deficit.
Etiology - Destroy skin cells, glands, hair shafts, nerves
Benefits: Massage may help with stress due to pain; massage may
- Thermal burns: temps above 115° F / 46° C - Can be white black charred edges help itching, mood, range of motion, quality of scar tissue
 Damage related to temperature, duration of contact - Risk of kidney damage from cellular debris in blood Options: Special massage therapy protocols for clients with burns
have been developed
 Skin function may be compromised - Risk of extreme scarring and contracture
Research: Massage has been seen to reduce itching and pain, to
 Regulation of temperature Signs and Symptoms improve the thickness of scar tissue, and to increase range of
 Limit fluid loss - Depends on heat source, depth of damage motion and elasticity
 Barrier from infection - Described with types
 Sensation Complications
- Chemical burns: - More than 15% of surface area affected raises risk for…
 Damage related to pH, concentration, duration of  Infection

contact
 Shock
 Acid burns stay superficial  Circulatory collapse
 Alkali burns penetrate through the fatty layer
What are they?
Burns are caused by damage to the skin that kills cells (melting the protein). They can be caused by thermal (wet or dry heat), radiation, corrosive chemicals (pH level, concentration, duration of contact, etc.),
and electricity.
- Seriousness of a burn is determined by depth and area involved, the individual’s age, and general health (other injuries and
preexisting conditions)
- Acid burns deep skin, but alkali burns melt through fatty layer and are more serious
- It impedes function: the ability to regulate temperature, control fluid loss, protection from microbial invasion, and sensory
information
- Local effect of a burn is the skin tissue directly in contact with the damaging agent
- Systemic effects of a burn are a greater threat to life and include:
1. Large loss of water, plasma, and plasma proteins which cause shock
2. Bacterial infection
3. Reduce circulation of blood
4. Decrease production of urine
5. Diminished immune responses
- Rule-of-nine method is used to determine the extent of a burn, the percentage are approximate body portion:
1. 9% = anterior and posterior surfaces of the head and neck
2. 9% = anterior and posterior surfaces of each upper limb
3. 36% = anterior and posterior surface of the trunk, including buttock
4. 18% = anterior and posterior surfaces of each lower limb, excluding buttock
5. 1% = perineum
- 70%+ is normally fatal
- 15%+ can put a person at risk of infection, shock and circulatory collapse
- Burns are graded by severity:
1. First-Degree Burns (superficial partial-thickness burns) [10%]
 Epidermis
 Mild pain and erythema (redness), pink, and dry but NO blisters
 Skin function remains intact
 Healing: 3-6 days (3-10 days), may be accompanied by flaking or peeling

Is massage indicated or contraindicated?
 Example, mild sunburn or diaper rash
2. Second-Degree Burns (partial or full thickness burns) [25%]

All burns locally contraindicate massage while they are acute,
 Epidermis and dermis because of pain and the risk of secondary infection. (One
 Redness, blister formation (full dry tissue paper, partial bullous blisters), edema, with waxy appearance and exception to this rule might be extremely mild sunburns that pain
would benefit from the application of soothing lotion)
 Blisters prevent the loss of body water and superficial dermal cells, “Natures” healing
 sensitive to temperature changes, air exposure, and touch.
 Some loss of function (1 month); hair follicles, sebaceous (oil) glands and sweat glands usually not injured
 Healing: (without infection) [7-10 days, 1-2 weeks OR] 3-4 weeks [scarring]
 Treatment: Dermal Regeneration Template (tissue engineered product) which is designed to promote regeneration of the dermis while providing a protective barrier against fluid loss and
microbes that has two layers:
I. Bottom layer: bovine (cow) collagen and carbohydrate glycosminoglycan (GAG), mimics the dermis
II. Outer layer: silicone layer, mimics the epidermis
3. Third-Degree Burns (full-thickness burn) [hands, feet, or perineum—anal and urogenital regions%]
 Dermis or deeper to the subcutaneous layer, may involve muscle or bone
 Vary in color from waxy white or yellow to tan, brown, deep red, or black charred edges
 Hard, dry and leathery
 If muscles is affected may cause kidney damage
 Edema, and the burned region is numb, NO PAIN, because sensory nerve endings have been destroyed
 Most skin functions are lost
 Healing: slow regeneration, much granulation tissue forms before epithelium
 Result in shrunken, contracted scar tissue that limits movement
 Treatment: skin grafting may be required to protect against fluid loss and infection, promote tissue healing, reduce scar formation, prevent loss of function, and for cosmetic reason
- Burns to the neck and face more serious because can lead to blockage
- Hot smoke inhalation can damage the trachea (windpipe) leading to inflammation restricting airflow into the lungs can produce wheezing or shortness of breath
 Treatment: oxygen face mask or a tube may be inserted into the trachea to assist breathing
- Burns that encircle the entire surface of the body or a part of the body are called circumferential burns
- An eschar is a slough or piece of dead tissue that is cast off from the surface of the skin, particularly after a burn injury
- Autografts - skin obtained from the person’s own body - autologous skin transplantation
 If the burn is too extensive could cause harm
 Small amounts of the epidermis is removed and keratinocytes are cultured in a lab to produce sheets of skin that is transplanted onto the burn and generate permanent skin
- Isograft – skin obtain from identical twin
- homograft - skin obtained from another human being, alive or recently dead
- heterograft (skin obtained from another species, such as pigs)
- Split-thickness skin graft is one that includes the epidermis and part of the dermis
- Full-thickness skin grafts include the entire thickness of the dermal layer
- Two-layered synthetic grafts, such as Apligraf or Integra, are composed of a layer of silicone, mimicking the properties of the epidermis, and a layer or matrix of fibers
- Apligraft and Transite grown in the laboratory from the foreskins of circumcised infants
Decubitus ulcers
Decubitus Ulcers
Definition Signs and Symptoms
- AKA bedsores, pressure sores, trophic ulcers - Stage I
- From inadequate blood flow when skin is compressed  Change in temperature, discoloration, pain and itching
Demographics  Damage may be deep
- 2.5 million people develop decubitus ulcers each year in the US - Stage 2
- Mostly…  Looks like full or ruptured blister
 Spinal cord injury patients - Stage 3
 Bedridden  Wound is a deep, open crater
 Wheelchair users - Stage 4
- A costly injury  Tissue loss, exposing deep structures
 $70,000 to treat a full thickness sore Treatment
 $8 billion/year - Preventable through hygiene and frequent position changes (before damage occurs)
Etiology - After damage occurs:
- Cells require blood supply to deliver O2, take away wastes - Topical antibiotics
 When capillaries are compressed, the cells they supply die - Special dressings
 Compression site can be a soft surface - Debridement
- Damage can penetrate to the bone - Surgical repair
- High risk of dangerous secondary infection - Electrical stimulation
- High risk of basal cell carcinoma - Whirlpools
- External Influences: Medications
 Pressure -Medicated dressings
 Friction -Topical or systemic antibiotics if necessary
 Shear (so changing positions may increase risk) Massage Therapy Implications
- Internal influences: Risks: Open wound and infection risk: these locally contraindicate massage
 Impaired pain sensation Benefits: Massage may be preventative—if the client has good sensation and skin quality
 Poor vasomotor response Research: Contradictory, but most agree that massage is better as a preventive measure than a
 Delicate skin treatment measure
- Most common sites:
 Sacrum
 Ischial tuberosity
 Elbows
Scar Tissue
Scar Tissue
Definition Complications Types of Scar Tissue Treatment
- Development of new cells, extracellular matrix after damage Hypertrophic Scars - Aesthetic treatments for shallow scars:
- Outcome of trauma, burns, surgery - Overflow boundaries  Collagen, fat injection
- This discussion looks at external scar tissue - May not be permanently enlarged  Dermabrasion
 For musculoskeletal scar tissue, see tendinopathies  (sometimes regress)  Chemical peels
Etiology Keloid Scars  Laser resurfacing
- Epidermis is set up to heal last - Overproduction of collagen  Skin grafts
- Under a new scab… - Permanently raised mass - Hypertrophic, keloid scars often recur
 Basal cells migrate in a single layer across the wound - Occasional complication of Medications
 Duplicate to build up strata  Deep injury -Injections of fillers
 Become Keratinized  Surgery -Application of engineered products for burns, ulcers
 Scab falls off  Piercing -Cortisol injections
- For deeper injuries… Contracture Scars Massage Therapy Implications
 Fibroblasts add collagen, other extracellular matrices - From a broad injury or burn Risks: Take care near unsealed wounds; watch for loss of sensation
(protein fibers and fluid) - Skin pulls together, tight web of connective tissue in old scar tissue
Signs and Symptoms - May limit range of motion at joints Benefits: Strong scar tissue has no contraindications
- Depends on circumstances Options: Careful work may help improve the quality of scar tissue
- Acne scars, stretch marks show where damage goes deeper Research: Massage has been seen to improve quality of life, pain,
than epidermis anxiety, muscle tension post-surgery; may be especially helpful for
- Deeper scars may have… burns and other trauma; no demonstrated benefit for keloids or
 Discoloration hypertrophic scarring
 Lack of pigment
 Lack of hair and glands
Scar Tissue How is it recognized?
What is it? Deeply scarred skin may lack pigmentation, hair follicles, and sebaceous (oil) and sweat glands. Common scar like striae (stretch
marks) and acne scars show when epidermis has been affected through stretch or pinching
Scar tissue is new tissue (extracellular matrix) that grows after an Is massage indicated or contraindicated?
injury, infection or surgery. It can grow in any kind of tissue. Deeper
wounds the granulation tissue becomes dense accumulation of Skin that is injured and not yet healed obviously contraindicates massage at least locally, because of both pain and the risk of infection
collagenous scar tissue.
Keloid scar or cheloid scar An elevated, irregular darkened area of excess scar tissue caused by collagen formation during healing. Scar extends beyond the original injury to
surrounding tissues and is tender and frequently painful. It occurs in the dermis and underlying subcutaneous tissue, usually after trauma, surgery, a
burn, piercing, or severe acne; more common in people of African descent.
Hypertrophic scars Over flow boundaries, but elevates skin. Appears a month or so after injury and then stabilize and
regress.
Contracture scars Skin heals but is pulled together in a tight web of connective tissue that may limit ROM over joints. Potential complication of burns and some surgeries.
Musculoskeletal System Conditions

Muscle Disorders
Muscular Dystrophy
Muscular Dystrophy
Definition Types of Muscular Dystrophy Treatment
- Group of neuromuscular diseases from genetic anomalies Duchenne Muscular Dystrophy - Nothing can reverse the genetic anomaly
- Most common are X-linked (carried by woman, passed on to - Most common, most severe - Surgery to release tight tendons
sons) - X-linked - Exercise as possible
Demographics - No production of dystrophin at all - Using assistive devices: Canes, walker, wheelchair
- All races Becker Muscular Dystrophy Medications
- Duchenne MD = 1:3,500 boys in US - Less common - Corticosteroids
- Becker MD = 1:30,000 boys in US - Less severe - Anti-convulsives, muscle relaxants
- Others are rarer - Only in boys - NSAIDs for pain
Etiology - Some dystrophin is produced, but not enough - Tricyclic anti-depressants for pain, depression
- Dystrophin helps convert glycogen into fuel for muscles Myotonic Muscular Dystrophy Massage Therapy Implications
- MD involves a problem with production of dystrophin - Most common adult-onset form Risks: Client may be generally fragile; muscle contractions require
 Cell membranes degenerate - Men and women care. Watch for other complications, including heart and kidney
 Muscle cells atrophy and die - Myotonia problems. Medications may also require adaptation
 Connective tissue shrinks into contracture  Stiffness or spasm after contraction Benefits: Massage may slow progression, preserve function, ease
Signs and Symptoms - Type 1, type 2 pain. Sensation is mostly intact, which makes massage safer than
- Vary according to type - Progressive otherwise
 Duchenne & Becker: a toddler begins to have trouble - Multisystem: Options: Passive stretching (along with PT) may slow progression
walking  Cataracts, GI dysfunction, arrhythmia Research: Lots of MD patients are CIH consumers, using massage
 Can progress to affect spine, joints, heart Other Varieties of Muscular Dystrophy to help slow progression
 May be accompanied by mental disability - Congenital MD
Complications  Identified at birth or early infancy
- Postural deviations - Facioscapulohumeral dystrophy
- Pressure sores  Affects facial and shoulder muscles
- Pain - Emery-Dreifuss MD
 Affects Achilles tendon, elbow, spine
- Oculopharyngeal MD
 Affects eyes, pharynx first
What is it? How is it recognized? Massage risks and benefits
Muscular dystrophy (MD) is a group of related inherited disorders Different varieties of MD affect different areas of skeletal muscles. Risks: Patients with MD may be fragile, and any bodywork must fit
characterized by degeneration and wasting of muscle tissue The age of onset, initial symptoms and long-term prognosis within their capacity to adapt. Late stages may involve respiratory
depend on what kind of genetic problem is present. or cardiac weakness, which must be accommodated.
Benefits: Because it doesn’t affect sensation, it is safe for MD
patients to receive massage. Body work as part of a health care
team may help to delay contractures and preserve function as long
as possible.
Spasms, cramps
Strains
Strains
Definition Signs and Symptoms Medications
- Injuries to muscle fibers: - Mild-intense local pain - NSAIDs for pain, inflammation
- Can be difficult to delineate from tendinopathies - Pain on resisted movement or passive stretching Massage Therapy Implications
Etiology - Usually no palpable heat or swelling Risks: Don’t irritate an acute injury
- Can be from trauma Treatment Benefits: Massage in later stages can be helpful with rehabilitation
- Usually from cumulative overuse (slow onset) - Early intervention makes a big difference Options: While acute, lymph drainage may be appropriate. Later,
- With the injury, fibroblasts churn out collagen  Get an accurate diagnosis friction + stretching and exercise may help improve the quality of
- Scar tissue may…  Control inflammation (PRICE) new scar tissue
 Impair contractility  Rehabilitate damaged tissues Research: Tests in animal models show good results for massage for
 Binding up fibers, nearby structures  Prevent further injury inflammation
 Cause adhesions
 Within the muscle
 Between the muscle and nearby tissues
- This raises risk for future injury
- Strain is an overstretch injury to a musculotendinous unit

- Musculotendinous unit = muscle, tendons, osseous and musculotendinous junction
- Weakest
 Older – overuse, overstretching, extreme contraction, and age related
 Young – not as likely because the bones haven’t ossified yet, more likely for fractures
 Most prone of rupture at the least vascularized area (middle or end)
- Contributing factors:
 Inadequate warm-up
 Limited flexibility
 Fatigue
 Overuse (especially in muscles across 1 joint, ex. rotator cuff muscles)
 Overstressing (especially in muscles across 2 joints, ex. gastrocnemius)
 Muscular imbalance
 Previous history
 Improper biomechanics
- Classified:
Grade Acute Subacute (Early-Late) / Chronic Chronic
General N/A Early - Bruising is gone
Repeated strains: - Pain, edema and inflammation are - Hypertonicity and TrP present
Result from overuse. still present but reduced from acute - Adhesions have matured
Chronic inflammation - Adhesions are developing around - Tissue may be cool due to
from continuing. injury site ischemia
Reduced strength. - Healing is relatively slow - Discomfort local to lesion site
- Protective muscle spasm diminishes when muscle is stretched
- TrP occur in affected muscle
Late
- Pain, edema and inflammation are
diminishing
- Protective muscle spasm replaced
by increased tone
- TrP occur in affected muscle
- ROM is reduced
1 - Local edema, heat and bruising are minimal or not present Early
Minor stretch to - Tenderness at the lesion site - Little or no pain and reduced strength
musculotendinous unit, - Little or no loss of strength of ROM N/A
minor discomfort local - C can continue activity
to injury site on activity  Address adhesions/scar tissue through stretching
(isotonic or stretching)  Micro-tearing from attempting to “push through” leading to chronic
inflammation / increases reoccurrence of injury and severity
2 - There is a snapping noise or sensation at the time of injury Early
There is tearing of - Moderate local edema, heat, hematoma and bruising are present - Pain and moderate reduced strength
several or many fibers - A gap may be palpated in the tissue - Muscle contour alteration
of the - There is moderate tenderness to the lesion site N/A
musculotendinous unit - There is moderate pain with activities that contract or stretch the musculotendinous
unity
- Moderate loss of strength and ROM
- C has difficulty in continuing ADLs due to pain
 Maintain ROM  strengthen
 Address adhesions/scar tissue through stretching
3 - There is a snapping noise of sensation at time of the injury Early
There is a complete - Marked local edema, heat, hematoma and bruising are present - Pain and reduced strength with ISO
rupture of the muscle - A gap is palpated in the tissue, muscle will likely bunch up due to spasm - Gap in tissue, muscle may bunch up unless surgically repaired
or an avulsion fracture - There is severe pain at the lesion site Chronic
of the tendinous - Immediate loss of strength and ROM - Non-surgical repair
attachment - Client cannot continue ADL - Reduced strength, but muscle can function
- Immobilized in a cast for 4-8 weeks (more in lower than upper body)
- Possible surgical repair
 Avoid atrophy (disuse)
 Address adhesions/scar tissue through stretching
2-3 - Bruising is red, black and blue Early
- Hematoma is present - Bruising, black and blue, hematoma
- Decreased ROM (guarding  spasm) - Muscle is still bandaged or casted to prevent further injury
- Little-severe loss of function, other structure compensate - ROM is reduced
- May be bandaged to prevent further injury (crutches, cane, sling, etc.) Late
- Bruising is yellow, green and brown, hematoma diminishes
- Gap is still palpable
Chronic
- Full ROM may be reduced
Assessments Acute Subacute Chronic

Observation - Antalgic gait if in lower limb/C unable to weight - Antalgic gait - Antalgic gait
bear (progressive severity of limp) - Supported limb - Gr. 2-3 Limb supported
- Supported by bandage or splint, crutches, cast, - Edema is diminished - Chronic edema if repeated strain
etc. - Hematoma resolving - Gr. 3 gap may be present still
- Pain or medicated fascial expression - Bruising diminishing to brown, yellow and green - Fascial distortion from swelling
- Edema - Alteration in contour or gap
 Gr. 1: minimal - Scar for surgery
 Gr. 2: moderate
 Gr. 3: visible local and distal
- Hematoma for Gr. 2-3
- Red, black and purple bruising local
- Redness local
- Gr. 2-3, gap and muscle contour alteration
Palpation - Heat - Temperature heat  nl - Cool due to ischemia
- Tenderness - Tenderness local - Tenderness local (C may be unable to sleep on
- Texture, edema (firm) - Edema (firm) that side)
- Hematoma - Adhesions - Adhesions mature, thickened
- Palpable gap or alteration in muscle contour - Hematoma diminishes - Palpable gap Gr2-3
- Protective muscle spasm - Palpable gap or alteration in muscle contour or - Hypertonicity for TrP
fascial distortion - Disuse atrophy
-Hypotonicity in atrophy (disuse)
-Hypertonicity with TrP
Range of Motion AROM AROM AROM
- Reduced - Limited ROM due to pain (less than acute), - End-range may be limited by pain
- Gr. 1 – mild pain, local pain during contraction or degree increases severity PROM
stretching, near nl ROM PROM - Mildly painful, tissue stretch or full stretching
- Gr. 2 – moderate pain, mid-range of ROM - Tissue stretch end feel before end-range ISO
- Gr. 3 – severe pain, loss of function (possible adhesions) - Decrease strength for Gr. 3 due to atrophy
PROM - Pain on tissue approximation
- Muscle spasm end feel at end range ISO
- Pain on tissue approximation - NOT performed maximally, but gradual strength
ISO - Gr. 1 – minor loss of strength, possible
- Gr. 1 minor loss of strength with discomfort discomfort
CI’d: - Gr. 2 – moderate loss of strength and pain
- Gr. 2-3 - (1) hearing or feeling a snapping - Gr. 3 – significant loss of strength and pain
sensation; (2) difficult in activity; (3) palpable gap Muscles prone to weakness: tibialis posterior and
REFER OUT anterior, peroneals, gluteus maximus and medius,
piriformis, iliopsoas, rhomboids, middle trapezius,
anterior neck flexors, anterolateral neck flexors and
posterolateral neck flexors
Special Orthopedic Testing Thompson’s Test (Achilles) Drop Arm Test (supraspinatus) Yergason’s Test (subluxation of the bicep tendon) Thomas & Ely’s (adductors, rectus
femoris) Piriformis & Hamstrings (SLR) Iliopsoas (Thomas and Fabere Test) Pectoralis major and minor & rotator cuff (Apley’s Scratch Test)
- Contraindications
 In acute Gr. 2-3 AROM is contraindicated to prevent tissue damage
 Avoid removing splinting in acute
 Distal circulation techniques are contraindicated in acute and early subacute to avoid congestion
 Gr. 3 casts, hydrotherapy contraindicated due to congestion
 Frictions are contraindicated if taking anti-inflammatories or blood thinners
 Hematoma local contraindication
Treatment
Acute Subacute (Early & Late) Chronic
Goals: reduce inflammation, reduce pain, treat compensating Early Goals: decrease pain, treat compensatory structures, reduce
structures, maintain local circulation proximal to injury, reduce but Goals: reduce inflammation, reduce pain, treat compensatory chronic edema, reduce hypertonicity and TrP, reduce adhesions,
DO NOT remove protective muscle spasm, DO NOT disturb structures, prevent adhesions, maintain local circulation proximal restore ROM, increase circulation, treat scar (surgical)
hematoma, maintain ROM, treat other conditions to injury, reduce spasm, reduce TrP, DO NOT disturb hematoma, - Hydrotherapy: deep moist heat or contrast
- RICE: Rest, ice, compression and elevation maintain range of motion - Rhythmical techniques
- Muscle placed in pain-free position - Elevation - Effleurage & Petrissage
- Position: client comfort - Hydrotherapy: contrast - TrP and muscle stripping, ischemic compressions
 Low back: supine 1-2 pillows under knees; prone pillow - Positioning: client comfort - Fascial techniques and stretching
under abdomen - DDB - Joint play and PROM
- Hydrotherapy: cold-ice - Rhythmical techniques - Stimulate (vibrations, tapotement, compressions) if atrophy
- DDB - MLD
- MLD & circulation - Effleurage & Petrissage
- Slower techniques - O&I, GTO & muscle approx for spasm
- Being away from lesion site or on contralateral limb - TrP, muscle stripping
- Effleurage, petrissage (FTK, PK, & C-scoop) - Gr. 1 move to local application
- DO NOT overtreat - Gr. 2-3 stroking, muscle squeezing, vibrations within pain
- Stroking and muscle squeezing distal for all grades tolerance
- PROM within pain tolerance, also increase MLD - PROM within C’s pain tolerance
Late
Goals: reduce pain, treat compensating structures, reduce edema,
reduce hypertonicity and TrP, reduce adhesions, increase ROM,
increase local circulation
- More vigorous techniques
- Elevate if still inflamed
- Hydrotherapy: contrast, ice if inflammation
- Rhythmical techniques
- Effleurage & Petrissage
- TrP and muscle stripping, ischemic compressions (pain
tolerance)
- Fascial techniques & stretching for adhesions and scar
tissue
- Joint play and PROM proximal and distal
- Gr. 1-2 on-site; Gr. 3 not local
- Self-Care
 Hydrotherapy reflects stage
 Self-massage
 Remedial exercise: N/A, but gradual increase, lengthen before strengthen
 Gr. 1 RPOM distal and proximal
 Gr. 2 ISO proximal
 Gr. 3 ISO and stretching
 Gr. 2-3 acute is contraindicated
 Advise for protective gear during activity if repetitive, may need to seek physician or physiotherapist
- Frequency
 Gr. 1 – 2 days
 Gr. 2 – several days to weeks
 Gr. 3 – 4-8 weeks and more, atrophy may take more sessions
Bone Disorders
Osteosarcoma
Osgood-Schlatter disease
Osteoporosis
Osteoporosis
Definition Osteoporosis Variables Complications
- “Porous bones” Calcium Absorption - Hip fractures (at neck of the femur)
- Calcium is removed from bones faster than it is replaced - Requires acidic environment in the stomach - Compression fractures (at the vertebral body)
Demographics  Dairy products impede absorption - Brittle ribs, wrists…
- 10 million in US diagnosed with osteoporosis (out of 311 mill)  Age limits HCl production Prevention
- 34 million may have osteopenia - Vitamin D and K improves absorption - Get dietary calcium from absorbable sources
- Women > men, 4:1 - Preformed vitamin A can increase the risk of fractures - Exercise
- More common in Caucasians and Asians than other races Calcium loss - Get vitamin D
- Usually in people over 60 years old - Lost with sweat and urine - Avoid substances and behaviors that decrease bone density
- Leads to 1.5 million hip, spinal wrist fractures/year - Meat-based proteins cause more Ca loss Treatment
Etiology - Menopause onset - Hormone replacement therapy
- We accumulate bone density until age 20-35  Changes osteoblast/clast activity - Synthetic calcitonin
 Then levels remain stable, or decrease  Can cause 30-40% of cortical bone loss - Bisphosphonates
 It is hard to increase bone density after age 35  Can cause up to 50% of trabecular bone loss - Selective estrogen receptor modules (SERMs)
- Turnover in bone minerals is steady, mostly happens in - High caffeine (3-4 or more servings/day) Medications
trabecular bone - Medications, radiation - Vitamin and mineral supplements
Non-Controllable Risk Factors - Underlying disorders - Hormones replacement therapy
- Gender (women have children, breast feed, are smaller) Bone Density Maintenance  Estrogen, calcitonin, parathyroid hormone
- Age - Osteoblasts and -clasts work under hormonal control - SERMs
- Body Size  Most active in trabecular bone - Bisphosphonates
- Ethnicity - We use Ca for other purposes - RANK ligand inhibitors
- Family history  Muscle contraction Massage Therapy Implications
Controllable Risk Factors  Blood clotting Risks: Risk of accidental fractures is substantial; take care with
- Hormone levels  Nerve transmission positioning and pressure on a table or massage chair. Elderly
- Vitamin D  These have higher priority than maintaining density people may also have other conditions simultaneously
- Medications  Osteoporosis reflects a loss in the balance between Ca Benefits: Massage may help with pain and movement
- Being sedentary additions and subtractions to the bones Options: use bolsters, pillows, etc. to make the client comfortable;
- Dietary Signs and Symptoms offer help to get on and off table
- Tobacco, alcohol use - Silent in early stages Research: Fracture has been reported as a massage therapy
Other Contributing Conditions - Then… adverse events; other research supports massage therapy as a may
- Diabetes  Spontaneous fractures to improve balance and decrease the risk of falls
- Anorexia, bulimia  Vertebral collapse
- Hyper / hypothyroidism  Hyperkyphosis and loss of height
- Rheumatoid arthritis  Acute, chronic back pain
- COPD
- Radiation, chemotherapy
Postural deviations / Hyperkyphosis (contains Scheuermann’s Disease), Hyperlordosis (contains Spondylolisthesis and Spondylosis) & Scoliosis
Postural Deviations
Definition Types of Postural Deviations Signs and Symptoms
- Overdeveloped spinal curves, or an S or C-curve Hyperkyphosis - Range from subtle to obvious
Etiology - Overdeveloped thoracic curve - May show on forward-bending test
- Spinal curves move out of normal planes  Can be related to osteoporosis and other conditions - Back pain, nerve irritation
- Often idiopathic  Scheuermann disease affects young men – - Compression of rib cage
 Possible factors include “Hunchback” Treatment
 Bone density Hyperlordosis - Usually treated with chiropractic or osteopathic manipulation,
 Environmental exposures - Overdeveloped lumbar curve exercise, physical therapy
 Genetic predisposition  Usually responds well to manual therapy - Bracing
 Other compensatory issues  Can cause significant low back pain - Surgery
Functional, Structural, and other Deviations Scoliosis, rotoscoliosis Massage Therapy Implications
Functional deviations - S- or C- cuver Risks: These can be related to serious underlying disorders;
- Often early stage - Affects 1-2% of teenagers accommodate appropriately. Hyperkyphosis is often seen with
- Soft tissues pull spine out of optimal alignment - Girls > boys osteoporosis and a risk of spontaneous fracture
 Can be reflective of distortions elsewhere - Usually a bend to the right Benefits: Massage may help address the soft tissue stresses that
- Most treatable with manual therapies - With a spinal twist = rotoscoliosis contribute to functional deviations
Structural deviations - Extreme cases can limit rib cage movement, risk of secondary Options: Addressing both shortened and lengthened muscles is
- Bones and joints change shaped to adapt problems important; many people add hydrotherapy elements, plus postural
- Difficult to reverse and movement training for the best outcomes
Sometimes related to underlying disease Research: Massage has been shown to help with soreness, range of
- Cerebral palsy, polio, etc. motion, and freedom of breathing
Hyperkyphosis (contains Scheuermann’s Disease)
- Hyperkyphosis is an increase in the normal thoracic kyphotic curve, with protracted scapulae and forward head posture
- Functional  muscle and posture
- Structural  bony
- Shoulder protractors and neck extensors inhibit the posterior thoracic muscles, anterior neck flexors, suprahyoids and infrahyoids produce cervical lordotic curve
- Causing restricted thoracic mobility and rib motion leading to respiratory conditions such as bronchitis
- TOS occur with tight anterior chest muscles
- Protraction from medial and inferior rotation of the GH joint
 Causes rotator cuff muscles to strain and place stress of joint capsule [frozen shoulder]
- Forward head posture
 Short muscles
 Pectoralis major and minor, levator scapulae, SCM, upper traps and scalenes
 Stretched muscles, weak or taut
 Rhomboids, middle trapezius, longus cervicis, longus capitis, suprahyoids, infrahyoids, thoracic erectors and lower cervical extensors
- Hyperkyphosis
 Stretched
 Abdominals
 Short
 hip flexors and lumbar erectors
- Pathologies that may lead to hyperkyphosis
 Osteoporosis
 Ankylosing spondylitis
 Pott’s disease
 Osteitis of the thoracic vertebrae due to TB
 Wedging of the vertebrae leads to gibbus deformity
 Leads to nerve root compression  epigastric or costal pain, coughing or difficulty swallowing and paresthesia in the hands
 Affects children and adults up to 40
 Scheuermann’s disease
 Idiopathic juvenile osteochondrosis of the thoracic vertebrae where the growth ossification center degenerate causing the posterior to taller than the anterior leading to wedging of the vertebrae
 Asymptomatic or mildly painful
 Occurs mainly in males
- Cause of hyperkyphosis:
 Sustained poor posture  slouching, fetal position sleeping) or emotional
 Occupational sources  computer, phone, drivers, etc.
 Over flexion or pectoralis strengthening exercises
 Pathology: osteoporosis or ankylosing spondylitis
- Symptoms
 Increased thoracic curve
 Scapular protraction
 Forward head posture
 Functional:
 Stretched posterior longitudinal ligament in the thoracic spine
 Facet joint approximation lead to cervical spine
 Tight ischemic tissue
 Over stretched
 TP
 Breathing limitations and rib hypomobility
 Muscle imbalances
 Shoulder protractors; upper cervical extensors are short and tight
 shoulder retractors; thoracic extensors; anterior neck muscles are weak and stretched
 Increased tone is rotator cuff muscles
 Entrapment of lymphatic vessels through pectoralis major = breast tissue congestion and edema
 ROM of thoracic, cervical and ribs are reduced
 Poor postural habits: slouching, hyperlordosis or flat back
 TOS and TMJ
 Structural:
 All the above
 Vertebral wedging or fusion
 Posterior displacement of the nucleus pulposus
- Assessments
 Postural
 Ankle plantarflexion
 Knee hyperextension
 Hyperlordosis
 Hip joints are flexed
 Anterior pelvic tilt greater than 10 degrees in females and 5 in males
 Thoracic curve increased
 AC joint may be anterior
 Cervical lordotic curve is increased
 Forward head posture
 Scapula protraction
 Winging of scapula
 Shoulder elevated, depressed or neutral
 Palpation
 Pectorals, SCM, anterior upper cervical extensors are tender and hypertonic and contain TP
 Pectoral fascia is thickened and tender
 ROM
 AROM
 Thoracic decrease extension
 PROM
 Cervical spine forward and lateral flexion reduced
 Shoulder protraction
 Reduced external rotation of GH joint
 ISO
 Weakness in trapezius and rhomboids
 Special Tests
 Length tests  pectoralis major, minor and shoulder adductors
 SLR  hamstring length test, decrease, posterior pelvic tilt
 Spurling’s Compression
 TOS special tests
- Differentiating Diagnosis
 Nerve root compression  Spurling’s
 Pott’s Disease
 Scheuermann’s disease
- Contraindications
 If believed to be bone pathology refer to physician
 Avoid hypermobile vertebral segments
 Joint play techniques for the ribs are contraindicated with rib hypermobility and a history of subluxation
 Be careful with fascia and lengthening techniques on weak or overstretched tissues
- Treatment Goals
 Hydrotherapy  pretreatment: heat applied to pectoralis and fascia; cool on weak rhomboids
 Decrease pain—decrease sympathetic nervous system firing
 Reduce fascial restriction
 Reduce hypertonicity
 Decreased TP
 Increase local circulation to remove metabolic waste
 Increase ROM in thoracic
 Stretch
- Frequency
 Once a week for 6 weeks
 Favorable
Hyperlordosis (contain Spondylolisthesis and Spondylosis)
- Hyperlordosis is an increase in the normal lumbar lordotic curve with increased anterior pelvic tilt and hip flexion
 AKA pelvic-crossed syndrome
- Iliopsoas increase normal lumbar lordotic curve
 Tilt pelvis anteriorly
- When iliopsoas is short, rectus femoris, TFL, quadratus lumborum and erectors also shorten
 Also adductors, piriformis with foot pronation
- Phasic overstretched/weak muscles are rectus abdominius, external and internal abdominal obliques and gluteus maximus
- Hamstrings become tight due to the raising of the ischial tuberosity
- Posture: hyperkyphosis and forward posture, pes planus, IT band contracture
- A pathology that may be present with hyperlordosis:
 Spondylolisthesis:
 A defect of the neural arch, consists of anterior slippage of the lumbar vertebrae following a bilateral fracture of the pars interarticularis
 Caused by hyperlordosis, congenital deformity or stress fracture
 Mostly in L5 and S1
 Asymptomatic or painful
 Spondylolysis
 Is a unilateral fracture of the pars interarticularis
- Causes:
 Sustained poor posture
 Slouched
 Prolonged standing
 Occupation
 Other postural conditions
 IT band contracture
 Weak abdominal muscles
 Pregnancy
 Obesity
- Symptoms
 Increase lumbar lordotic curve
 Anterior pelvic tilt
 Pes planus
 Knee hyperextension
 IT band contracture
 Hyperkyphosis
 Muscle imbalances: hip flexors and lumbar extensors (short), abdominals are weak (stretched), hamstrings and gluteus maximus are tight (stretched), adductors short (tight)
 Pain
 Ligaments, facet joint approximation, posterior disk and intervertebral foramen narrowing with nerve root compression
 Ischemic tissue
 TPs
 ROM hip extension restriction
- Assessments
 Observation
 Posture
 Ankle plantarflexion
 Knee hyperextension
 Hip joint flexion
 Anterior pelvic tilt (greater than 10 degree for females and 5 degrees for males)
 Lordotic curve increased
 Hyperkyphosis
 Forward head posture
 Pes planus
 Abdominal or lumbar scarring (surgery)
 Palpation
 Tenderness
 Hypertonicity
 TP
 MUSCLES: erectors, QL, iliopsoas, TFL and rectus femoris
 Texture of lumbar and IT band is thickened and reinforced
 ROM
 AROM
 Trunk and hip flexion short
 Hamstring lengthened
 Spinal extension may aggravate low back pain/hyperlordosis
 PROM
 Hip extension restriction
 ISO
 Reveal iliopsoas as strong
 Abdominals are weak
 Special Tests
 Thomas test
 Iliopsoas, rectus femoris and IT band
 Ely’s test
 Rectus femoris
 Ober’s test
 TFL and IT band
 Piriformis length test +
 SLR
 Hamstring length decreased
 Differential Diagnosis
 Space-occupying lesions
 Disc herniation (valsalva’s, Kemp’s, Kernig’s, SLR, DTR and gastro ISO R/O)
 SI joint mobility and dysfunction (gapping, squishing, Gaenslen’s and Faber test)
 Hip pathology (scouring test, faber and faddir)
 Spondylolisthesis (Stork test)
 Visceral pathologies
 Renal and urinal
 Bone and prostate cancer
 Contraindications
 If low back pain is present, R/O potential pathological sources before treatment, refer out
 Avoid mobilizing hypermobile vertebral segments
 Do not randomly stretch fascia
 Do not compress over palpable vasculature, including the aorta when massaging the abdomen or the femoral artery when massaging the upper medial thigh
 Avoid lengthening techniques on weak, overstretched tissues
 Treatment Goals:
 Hydrotherapy  heat to IT fascia and rectus femoris (supine), (prone) lumbar fascia
 Decrease pain—decrease sympathetic nervous system firing
 Reduce fascial restrictions
 Reduce hypertonicity
 Reduce TP
 Increase local circulation and remove metabolic waste
 Stretch shortened muscles
 Mobilize hypomobile joints
 Restore range of motion  increase range of motion
 Strengthen weak muscle
 Treat other conditions
- Frequency
 Favorable
Scoliosis
- Clinical 70 pg. 569
Joint Disorders
Adhesive Capsulitis / Frozen Shoulder
Frozen Shoulder / Adhesive Capsulitis

Definition Signs and Symptoms Treatment
- Connective tissues at the glenohumeral joint become inflamed - Freezing - Depends on stage
and restrictive  Begins with pain in 1 shoulder, usually at night - No single treatment seems to shorten the cycle
- Several months to develop, stabilize, and resolve  Severe and slowly progressive - Analgesics
Demographics - Frozen - Corticosteroids injections
- Most common in people 50-60 years old  Stabilizes, stiff but not painful - Surgery
- Often seen with diabetes, hyperthyroidism, high triglycerides  Active and passive movement is limited - Joint manipulation
- Usually unilateral, but may occur later in the other shoulder o Especially in external rotation, abduction, - Nerve block
Etiology flexion Medications
- Not clear - Thawing - Analgesics: NSAIDs to narcotics
 Could be adhesion between joint capsule, head of  Process reverses - Corticosteroids injections
humerus  Full or nearly full function returns Massage Therapy Implications
OR… - Whole process: 9 months – 3 years Risks: The “freezing” phase can be exacerbated by careless
 Could be begin outside the joint, and inflammation at massage; painkillers may mask symptoms
the joint is a reaction Benefits: Massage may work with PT and other interventions to
- Biopsied connective tissue looks like other CT problems improve ROM and postural compensation
- Excessive pain signals look like other CNS problems Options: Work to the shoulder girdle may be helpful if it doesn’t
exacerbate symptoms
Research: Findings for massage therapy are mixed, but experts
agree that this calls for a highly individualized approach
Adhesive capsulitis, also known as frozen shoulder, is an idiopathic Adhesive capsulitis has a predictable pattern of slowly progressive Risks: When this condition is acute and worsening, massage may
condition in which the connective tissues of the glenohumeral joint pain and loss of both active and passive range of motion, followed exacerbate pain and inflammation. Also, patients may use mild to
capsule and surrounding areas become progressively inflamed, by a period of stability, which then usually fully or mostly resolves. very strong analgesics to manage this process, which can mean
painful, and thickened, which radically limits range of motion. The whole process can take between several months and 2-3 that body work must be done with extra care.
years. Benefits: During the phases when pain and inflammation are less
extreme, massage and other manual therapies may be used in
addition to other interventions to help restore freedom of
movement and shorten recovery time.
- Frozen shoulder is painful, significant restriction of active and passive range of motion at the shoulder, most frequently in abduction and external rotation
- Aka adhesive capsulitis, capsulitis, periarticular adhesions, rotator cuff tendinitis and periarthritis
- Joint capsule becomes tightened and inflexible
- 2-3% of the pop.
- Affects more women
- Rarely occurs in those under 40 or over 70
- 3 stages:
1. Acute  joint capsule becomes painfully contracted with a loss of the axillary recess
2. Subacute  capsular fibrosis occurs
3. Chronic stage  range gradually returns
- Causes:
 Idiopathic factors
 Intrinsic musculoskeletal trauma or disorder such as impingement syndrome, subacromial bursitis, rotator cuff tendinitis or tears, dislocations, osteoarthritis, gout and inflammatory synovitis
 Trigger points in subscapularis muscle
 Postural dysfunction such as hyperkyphosis, protracted scapulae and forward-head posture
 Disuse following shoulder injury or immobilization
 Extrinsic disorders such as myocardial infarction, hemiplegia, pulmonary disorders such as chronic bronchitis or emphysema, previous breast surgery include mastectomy, lymph node biopsy, coronary bypass surgery and fractures of the humerus
 Systemic disease such as diabetes and hyperthyroidism
 People with diabetes have 10-20% incidence
 Those who are insulin dependent and who have had diabetes for longer than 10 years are particularly likely to develop frozen shoulder
- Motion at the Shoulder Joint
 Composed of the SC, AC and scapulothoracic articulation, along with the GH joint
 Abduction require scapular rotation, elevation of the clavicle
 Extension and side bending of the thoracic and exaggeration of the lumbar lordosis, as well as elevation of the humerus
 Humerus must externally rotate to prevent greater tuberosity from impinging on the acromial arch, (restrict abduction)
 1st and 2nd rib must descend to allow full vertebral motion
- Medical Treatment of Frozen Shoulder
 Analgesics, anti-inflammatories and steroids
 Distention arthrography
 Joint mobilization under anesthesia
- Symptoms
 Acute = “freezing phase” or “painful phase”
 Minor pain due to twisting
 May be immobilized
 Major trauma like fracture, surgery or myocardial infarction
 Severe pain at night (unable to lying on affected side)
 Referring pain to elbow
 Muscle spasm in rotator cuff muscles
 Inflammation of joint capsule
 Stiffness progresses 2-3 weeks after pain begins
 Lasts 2-9 months or longer
 Unilateral or bilateral (non-dominant hand may be more affected)
 2nd shoulder involvement in 10-20%
 Acute and subacute stages blend together
 Subacute = “frozen phase” or “stiffening phase”
 Severe pain begins to diminish, particularly end range
 Stiffness become CC
 Activity limitation of ADL
 Capsular pattern: external rotation, abduction and internal rotation
 Atrophy of deltoid and rotator cuff muscles may occur
 Last 4-12 months
 Chronic = “thawing phase” or “resolution phase”
 Pain is localized to lateral arm and continues to diminish
 Night pain is gone
 Motion and function gradually return
 Full ROM is not always regained
 2-5 or 10 years
 Correlation between pain and recovery phase
- Special Tests
 Gait  arm is held at side, swing arm absent
 Posture  forward head posture and kyphosis
 Elevated and protracted scapula
 Palpation
 Hypertonicity and TPs in the trapezius, levator scapula and shoulder girdle muscles
 Lateral arm tender
 Atrophy and fibrosing in rotator cuff muscles in subacute
 Testing
 Capsular pattern
 Acute = 70-90 abduction; subacute 90 abduction, 120 flexion, 60 external and 45 internal rotation with leathery end feel; ROM increases
 Apley’s scratch test
 First rib mobility test
- Differential Diagnosis
 Posterior dislocation
 AC joint sprain
 Tendinitis
 GH osteoarthritis
 Cervical nerve root pathology
 Cervical facet joint irritation
 Reflex sympathetic dystrophy
 Referred shoulder pain
- Contraindications
 Aggressive stretches and joint play mobilizations greater than Grade 1-3 are contraindicated in acute stage
 Frictions are contraindication with anti-inflammatory medication
- Treatment Goals
 Maintain ROM  increase ROM
 Maintain strength  increase strength
 Stretching  passively or self care
 Wall-walking exercise
 Reduce pain—reduce sympathetic nervous system firing
 Treat compensating structures
 Reduce Spasm
 Reduce TPs
 Maintain local circulation
 Joint mobilization and PROM
 Treat other conditions
 Kyphosis
 Reduce inflammation
 Reduce fascial restrictions
Baker Cysts
Baker Cysts
- Synovial cysts in the popliteal fossa - Often silent
- AKA popliteal cysts - Affected knee may have pain from underlying cause
Demographics - Feeling of tightness, fullness during flexion
- Common in children - May be visually obvious
- In adults, usually with some other joint problem Treatment
Etiology - Ice
- Knee joint capsule or posterior bursa forms a pouch that protrude posteriorly - NSAIDs
- May prohibit fluid from re-entering the joint capsule - Cortisone injection (often recur)
- In adults, usually seen with: - May need surgery to correct underlying situation
 Osteoarthritis Medications
 Rheumatoid arthritis - NSAIDs for pain and inflammation
 Lupus Massage Therapy Implications
 Gout Risks: Local contraindication, watch for signs of thrombosis
 Knee injuries Benefits: Massage elsewhere on the body is safe if no signs of thrombosis are present
- Possible for a cyst to impede flow through the lesser saphenous vein
 Thrombophlebitis, DVT risk
Baker cysts are synovial cysts, usually found on the posterior Baker cysts are palpable deep to the superficial fascia in the Risks: Deep work in the popliteal fossa is general not
aspect of the knee. They are often connected to the synovial popliteal fossa. They may cause pain on knee extension, or a recommended regardless, but the presence of a cyst that could
capsule of the knee. feeling of tightness in flexion. rupture makes it even more important to avoid intrusive pressure
in this area. In addition, Baker cysts may be large enough to
interfere with blood return from the leg. This raises the risk of
thrombosis, which must be cleared before bodywork is safe.
Benefits: While large Baker cysts locally contraindicate massage,
bodywork elsewhere is safe. A client who have fully recovered
from Baker cyst treatment can enjoy the same benefit.
Gout
Gout
Definitions Etiology Treatment
- Inflammatory arthritis - Uric acid is a by-product of digestion - Get an accurate diagnosis
- One of the oldest diseases in the medical record  Especially of foods high in purine  (pseudogout needs different treatment)
- “disease of kings” - If it is not shed, hyperuricemia develops - Work for…
 Alexander the Great; Henry VII; Charles V of Spain;  Sign of kidneys not keeping up with demand  Pain relief without aspirin
Phillip II of Spain; Benjamin Franklin… - Often a triggering event sets it off:  Reduce inflammation
Demographics  Binge eating or drinking; surgery; sudden weight loss  Modify uric acid processing
- Mostly in men 40-50 - Crystals form in interstitial spaces, especially at medial aspect Medications
- Rare in women before menopause of the great toe - NSAIDs
- Risk factors:  They attract WBCs; extreme inflammatory response - Steroids
 Genetics; diet; medications; history of psoriasis - Later: deposits of crystals settle around and inside joints - Colchicine
Signs and Symptoms  “Trophi”; can erode into bones; destroy the joint - Metabolic drugs
- Sudden onset - Link between hyperuricemia and a gouty attack is not always Massage Therapy Implications
- Usually in the feet, may spread from there consistent Risks: An acute flare of gout is likely to cause a person to
- Joint swells  May have to do with whether the uric acid is coated reschedule an appointment. It is at very least a local
 Hot, red, shiny, painful; may show fever with a protective layer to quell inflammation contraindication simply for pain. Sites of previous attacks need
Complications - Some people have repeated episodes special care—no “grinding out uric acid crystals”
- May spread to other joints  Occur closer and closer in succession; may involve Benefits: A person who have recovered from gout can enjoy the
- Can be associated with other joints same benefits from massage as the rest of the population
 Kidney stones
 Renal failure
 Hypertension
 Atherosclerosis
 Stroke
- Demonstrates close link between cardiovascular disease and
kidney health
Gout is an inflammatory arthritis caused by deposits of Acute gout causes joints to become red, hot, swollen, shiny, and Risks: Acute gout locally contraindicates massage simply because
monosodium urate (uric acid) in and around joints, especially in extremely painful. It usually has a sudden onset. of pain, inflammation, and the risk of exacerbating damage. It may
the feet. also systemically contraindicate all but the most gently types of
bodywork: this is a severe and acute condition that suggests
serious metabolic problems that must be addressed
Benefits: Joints with a history of multiple gout episodes may be
permanent sites of caution, depending on how much damage
might have accrued. A client with a history of successfully treated
gout but no current symptoms can enjoy all the benefits of
massage everywhere else on his or her body.
Joint disruptions / Dislocation & Subluxation
- Dislocation is the complete dissociation of the articulating surfaces of a joint

- Subluxation is when the articulating surfaces of a joint remain in partial contact with each other
- Most frequent GH (relies largely on ligaments and muscular support)
- Also AC joint, metacarpals and interphalangeals
- Hip least likely, ankle, knee, hip and elbow require greater force
- Dislocation  portion of joint capsule or ligament completely or partially tear
o Tendons, synovial sheath and cartilage may also be damaged
- Dislocation  contusions and strains likely to occur
- Dislocation  complications nerve and vascular damage and fracture (osteochondral fracture)
- Subluxation  joint capsule is stretched and may result in sprain
- The cause of a dislocation is trauma-related sudden twist or wrench of the joint beyond its normal range of motion
- Contributing factors
o Pathologies
 Rheumatoid arthritis, paralysis and neuromuscular diseases (stroke)
o Congenital ligamentous laxity or joint malformation
o Previous dislocation
 Often leads to joint instability
- Treatment
o Joint reduction (putting it back into it’s socket)
o Muscle spasm  muscle relaxant or anesthetics
o Joint is supported for several weeks
o Surgery may be required if labrum tears (possible staples), pins and screws may be used
- Dislocation of Specific Joints
o GH most common form
 Most common:
 Anterior dislocation or subcoracoid dislocation
o Often excessive abduction and external rotation ex. throwing a ball
o Extension ex. falling backwards
o Force head through inferior portion of the joint capsule forcing it inferior to the coracoid process
o Axillary nerve may be injured
o Reduction and sling for 3-6 weeks
 Younger people arm may be bandaged to thorax for 2-3 weeks
 Elderly 10 days
o Putti Platt surgery involves shortening the subscapularis muscle to limit external rotation of GH
o Bankart procedure reattaches the GH joint capsule to the glenoid fossa using arthroscopy (immobilized for 4 weeks)
 Least common:
 Posterior dislocation
o Mechanism is flexion, adduction and internal rotation ex. person falls forward with elbow flexed
o Patella
 In a lateral direction
 Mechanism involves external rotation of the tibia and foot when the knee is flexed
 Repeated dislocation the quadriceps may be surgically transpose to a more medial location ensuring patellar tracking is more medial
 Immobilized for 6-9 weeks
o Lunate
 Mechanism hyperextension ex. fall on the outstretched hand
 Wrist immobilized 4 weeks
 Complications
 Median nerve lesions and necrosis of dorsal ligaments connecting the lunate to the radius
o Elbow
 Accompanied by fracture
 Mechanism fall on outstretched hand or motor vehicle accident
 Ulna and radius displaced posteriorly
 The brachial artery, median and ulnar nerve may be involved
 Immobilized for 3 weeks
 Myositis ossificans complication
o Hip dislocation
 Uncommon
 Mechanism femur forced posteriorly by direct impact to the knee ex. car (dashboard) or motorcycle accident
 Include along side fracture of the acetabulum and compression of the sciatic nerve
 Immobilized for 6 weeks
- Symptoms
o Acute
 Rupture of joint capsule and supporting ligaments or an avulsion fracture
 Snapping or popping noise heard at time of injury
 Pain intense
 Joint appears deformed
 Local edema and heat  joint effusion if capsule is damaged  hemarthrosis if blood goes into joint capsule
 Joint is unstable
 Complications: strain, contusions or hematoma, blood vessel and nerve injury and fractures
 Bruising red, black and blue
 Decreased ROM, protective muscle spasm, edema and pain limits movement
 Decrease in activity
o Early Subacute
 Joint is unstable
 Bruising is black and blue
 Hematoma still present
 Pain, edema and inflammation diminish
 Adhesions are developing around injury
 Slow for capsule and ligaments for they are hypovascular
 Protective muscle spasm diminishes
 TPs occurs in muscles crossing joint or compensatory muscles
 ROM is reduced
o Late Subacute
 Bruising changes to yellow, green and brown
 Pain, edema and inflammation diminish
 Adhesions mature
 Muscle spasm replaced by hypertonicity
 ROM is reduced
o Chronic
 Local pain to joint capsule or when stressed
 Bruising is gone
 Adhesions have matured
 Hypertonicity and TP are present
 ROM is restricted
 Pocket edema local to ligament
 Tissue is cool due to ischemia
 Muscle weakness from disuse/atrophy
 Loss of proprioception
- Special Tests
o Observation
 Acute
 Gait if weight bearing joint
 Antalgic posture  arm held against body
 Pain or medicated fascial expression
 Edema
 Redness
 Red, black or purple bruising
o May be hematoma
 Subacute
 Antalgic gait still present
 Edema is diminished
 Bruising purple and black to brown yellow and green
o Hematoma diminishing
 Scar may be present
 Chronic
 Antalgic gait
 Residual edema local
 Scarring
o Palpation
 Acute
 Heat, tenderness, edema texture, protective muscle spasm
 Subacute
 Temperature heat/cold, tenderness, edema or adhesions texture
 Muscle tone instead of muscle spasm, tightness
 TPs present
 Chronic
 Temperature cool (ischemia), tenderness local, adhesions texture to capsule and ligaments
 Hypertonicity, atrophy and TP
o Special Tests
 Acute  contraindicated unless pain-free AROM
 Chronic
 Apprehension tests
o Patellar apprehension
 Apley’s scratch test
 AC joint shear test
 Ligamentous stress tests
 ROM  Passive for overpressure and ISO for atrophy
- Contraindications
o Acute and subacute stages, testing other than pain-free AROM to prevent tissue damage
o Avoid removing the protective splinting of acute and early subacute dislocations
o Distal circulation techniques are contraindicated in acute and early subacute to avoid congestion
o If joint is unstable, DO NOT place the limb in the position of injury
 Avoid rhythmic techniques or ROM exercises
o Joint play is contraindicated
o Frictions are contraindicated if taking anti-inflammatories or blood thinners
o Avoid heavy hydrotherapy application, particular hot for congestion, especially under cast
o Remedial exercise in acute contraindicated
 Make sure muscle strength has returned
- Treatment Goals
o Refer out if acute and no reduction has occurred—medial emergency
o Reduce inflammation, edema
 Proximal contrast towels hydrotherapy application
o Reduce pain—decrease sympathetic nerve firing
o Treat any compensating structures
o Maintain local circulation proximal to injury  increase local circulation
o DO NOT remove protective muscle spasm later reduce
o Maintain range of motion  gradually increase ROM
o Treat other conditions
o Prevent adhesion formation  reduce adhesions
o Reduce TPs
o Reduce hypertonicity
- Treatment Frequency
o More frequent shorter treatments for acute
o Progress to once a week for chronic
o Return to normal activity once apprehension tests are negative
o Complete healing of ligaments requires 6 months for full maturation of collagen fibers
Joint replacement surgery
Lyme Disease
Lyme’s Disease
- Infection with Borrelia burgdorferi - Early localized disease: - Get an accurate diagnosis
- Spread by 2 species of tick:  1st stage - Consider Lyme disease with symptoms of…
 Deer tick (Ixodes scapularis)  Appears 7-30 days after tick bite - Antibiotics
 Western black-legged ticks (Ixodes pacificus)  Bull’s-eye rash in <50% of all cases - Protect from tick exposures
Demographics  High fever Medications
- Reported in most states  Night sweats - Antibiotics
- Mostly in NE, Mid-Atlantic, upper Midwest, Northern California  Swollen lymph nodes Massage Therapy Implications
- Most common vector-borne illness in US  Looks like cold or flu Risks: Acute inflammation contraindicates massage therapy, at
- 30,000 infections reported/year (real # may be much higher) - Early disseminated disease: least locally. Important to be part of a well-informed health care
- Most at risk: those who work or play in wooded areas  2nd stage team
Etiology  More rashes Benefits: Massage therapy may help with anxiety, stress
- Ticks pick up bacterium from an animal host (mouse)  Cardiovascular symptoms Options: If you work in a high-risk area, become familiar with what
- Bites human, transmit bacteria to bloodstream  Headaches ticks look like; how to remove them
- Adults and nymph can transmit disease  Bell palsy Research: one case study found positive effects in periods when a
- Bacteria enters the bloodstream, travels to other tissues  Forgetfulness, fogginess client received massage; negative effects when massage was
- B. burgdorferi is slow-growing  Shooting pains ceased
 Delayed immune response  Debilitating fatigue
 Delayed accurate blood test - Later disease:
 Several different strains  Final outcome
- Lyme disease is not the only tick-borne disease  Extreme inflammation at one or more large joints
 Other may be comorbid  Knee
 Shoulder
 Elbow
- This is why Lyme disease is considered a joint problem
- 10-20% develop chronic muscle, joint pain: posttreatment Lyme
disease syndrome
 Could be autoimmune reaction
Osteoarthritis
Osteoarthritis
Definition - Contributing factors:
- A condition in which synovial joints lose heathy cartilage  Age
- Different from other types of arthritis because…  Overweight
 Wear and tear  Link between adipocytes and cartilage degeneration
 Biomechanical factors  Lax ligaments
 Consequences of inflammation  History of trauma or surgery
Demographics  Repetitive pounding stress
- Most common form of arthritis  Hormonal imbalances
- 27 million people in the US Signs and Symptoms
- Up to 50% of the population over 65 years old - Seldom hot, painful, swollen
Etiology - Usually deep pain and stiffness
- Lasting imbalance in joints can have destructive impact - Possible crepitus
- Once the process begins… - May be triggered by changes in weather
 It can be slowed or stopped - At the fingers:
 It is difficult to reverse  Heberden nodes - DIP
- Degeneration begins with articular cartilage  Bouchard nodes - PIP
- Progresses to affect synovium, bones Treatment
- Begins with damage to articular cartilage - Goals:
- Cartilage is constructed of…  Reduce pain and inflammation
 Chondrocytes  Limit or reverse damage to joints
 Collagen - NSAIDs
 proteoglycans - Counterirritant ointments
- Arranges in 3 zones - Physical therapy and exercise
 Superficial - Nutritional supplements
 Intermediate - Corticosteroid injection
 Deep - Joint lavage and debridement
- Deep zone is attached to the chondral surface of the bone - Joint replacement surgery
- Zones allow cartilage to resist shearing and compression Medications
- Chondrocytes constantly replace and rebuild cartilage surface - Topical counterirritants
 They don’t proliferate readily - NSAIDs, including Cox-2 inhibitors
 They become less active with age - Other analgesics
 Cartilage degenerates, chondrocytes can’t keep up - Injected steroidal anti-inflammatories
 Accelerates with pro-inflammatory chemicals Massage Therapy Implications
- Inflammation Risks: acute inflammation contraindicates massage, but this is rare with osteoarthritis
 Swells the synovium Benefits: massage therapy reduces pain and stiffness and appears to improve function for
 Suppresses chondrocyte activity osteoarthritis patient
- Damaged cartilage stimulates osteocytes Research: Whole-body massage therapy, massage directly to the knee, and self-administered massage
 Epiphyses enlarge to the knee have all shown to be beneficial for knee osteoarthritis symptoms; it is not a huge stretch to
 Bone spurs develop suggest similar results for osteoarthritis in other joints
 Cavities under the cartilage
Patellofemoral Pain Syndrome
Patellofemoral Pain Syndrome

- A group of conditions in which the patellar cartilage becomes - Pain at the anterior aspect of the knee - NSAIDs
irritated - Stiffness after rest Massage Therapy Implications
- Can be a precursor to osteoarthritis at the knee - Difficulty walking downstairs Risks: this carries no particular risk; directed downward pressure
- Synonyms: Chondromalacia; jumper’s knee; moviegoer’s knee; - Crepitus on the patella may be irritating
anterior knee pain syndrome; overutilization syndrome - Can look like tendinosis, which responds to massage Benefits: bodywork specifically for the knee and whole body can
Demographics Treatment help address tension and stiffness
- Very common: most frequently documented knee injury - Find strategies to slow or stop the progression, without Options: work to equalize tension on either side of the patella
among adolescents and adults becoming sedentary
Etiology  Replace percussive activity with non-percussive activity
- Any time the knee is in flexion, the patella presses into the  Exercise to strengthen and balance tension in muscles
femur that cross the knee, deep lateral rotators
 Pressure must be evenly distributed, or cartilage is - Ice
damaged - NSAIDs
 Long-term irritation leads to osteoarthritis at the knee - Orthotics
- 2 main contributors: - Improved footwear
 Overuse/overloading - Knee brace or taping
 Poor alignment; exaggerate Q angle - Possible surgery
Patellofemoral syndrome (PFS) is an overuse disorder than can PFS causes pain at the knee, stiffness after immobility, and Risks: Massage carries no particular risks for PFS
lead to damage of the patellar cartilage discomfort in walking down stairs Benefits: If damage has already occurred to the patellar cartilage,
massage is unlikely to reverse that process. However, both general
and specific massage can help deal with discomfort and muscular
tension that may develop when the knee is stiff and painful
- Patellofemoral syndrome, also called patellofemoral tracking disorder describes various painful degenerative changes to the articular cartilage on the underside of the patella
- 65% due to tracking or instability
- Patella a sesamoid bone
 Attaches to the quadriceps tendon and patellar tendon
 Stabilized by the patellar retinacula
- When the knee is extends the patella glides superior to the femoral condyles
- When the knee is flexed the patella glides inferior to the condyles
- Q angle
 Slight valgus angulation from the femur and tibia
 Causes a slight lateral pull on the patella
 Patellar groove in the femur prevents this lateral movement
 However, during full knee extension, patella glide superiorly into the shallower portion of the femoral groove
 The vastus medialis obliquus and medial retinaculum prevent the patella from tracking laterally
 Import for knees bearing a load
 The lateral and medial facet (30% missing in the pop.) aid in this
- Patella cartilage is thing and yellows with age (from white-blue)
- Causes:
 Abnormal biomechanics
 Foot pronation
 Internal rotation of the tibial or femur  increased Q angle
 Small, high-riding patella (patella alta) because it lies in the shallow portion of the femoral groove thus tracking laterally
 Tight lateral structure  vastus lateralis, lateral retinaculum, IT band and TFL
 Tight posterior and anterior structures  hamstrings, gastrocnemius and rectus femoris
 Restrict ankle and knee movement
 Weakness  vastus medialis obliquus, which allows the lateral motion of the patella, gluteus medius, which allows medial rotation of the femur
 Knee injury  subluxation
 Arthroscopic procedures  iatrogenic lesions of the cartilage
 Repeated knee stress
 +
 Increase knee flexion and stress can produce degenerative changes, synovial irritation, inflammation and pain
 Medial facet is less dense therefore during knee flexion does not receive enough compressive stress
 Patella can rotate slightly during knee extension
 Basal degeneration --? Failure of the cartilage to absorb stresses in the knee and place more on the subchondral bone/interosseous causing pressure thus pain
- Treatment
 Most common is NSAIDs for 1 month and remedial exercises, SLR and knee extension for 8-12 weeks
 Is also taped to ensure proper tracking of the patella
 Surgery is rarely used
- Associated Conditions
 Chondromalacia patella  softening of the cartilage of the patella
 Plica syndrome  synovial fold at the knee (plica) is thickened from overuse causing pain
 BUT has crepitus and a taut palpable tender band medial to the patella for the syndrome
- Symptoms
 Patella pain
 Difficult sitting for long periods of time, AKA move theatre sign, walking down stairs, squatting and running downhills
 Feeling like the knee is going to ‘give way’
 Crepitus is present
 Swelling
 Atrophy of the quadriceps muscles
- Assessments
 Observation
 Posture
 Pronation of the foot
 Valgus knee
 Squinting patella
 Feet are externally rotated but the patella is more medial
 Hypotrophy of vastus medialis
 Possible hyperextension of the knee
 Gait
 Thigh internally rotates and adducts to midline so the weight bearing foot is placed under the centre of the pelvis
 Gluteus medius weakness, Trendelenburg gait
 Palpation
 Medial and lateral borders of the patella are tender
 Swelling
 Medial patella is palpated for vertical taut band of the plica cord
 ROM
 Crepitus of the patella
 AROM
 Lateral motion of the patella during knee flexion
 PROM
 Tightness or hypomobility for the ankle, hip or SI, or lumbar
 Gastro may be short during knee flexion
 ISO
 Gluteus medius weakness
 Special Tests
 Length tests
 Hamstrings, gastrocnemius
 Q-angle (18 degrees when client is standing)
 Waldron’s, McConnell’s and Clarke’s patellofemoral grind tests
 Patellar Apprehension test
 Ober’s test for IT band
 Differential assessment
 Patellar tendinitis is pain on compression at inferior patella during knee squats
- Contraindications
 If any inflammation is present avoid using hot local hydrotherapy or local techniques such as frictions at site of lesion
 Full flexion PROM with overpressure is contraindicated if pain is present
- Treatment Goals
 Hydrotherapy  deep moist heat to the IT band and lateral retinaculum or contrast to improve circulation
 Increase ROM on low back, gluteus, lumbar and SI joints
 Increase extensibility of the IT band, lateral retinaculum and hamstring
 Decrease muscle tone – TFL, gluteus medius, hamstrings and gastrocnemius
 Increase tone on vastus medialis due to weakness
 Stretches for hamstrings and gastrocnemius
 Increase circulation and metabolic waste
Spondylolisthesis
Spondylolisthesis
Definition Types of Spondylolisthesis Signs and Symptoms
- A structural problem in the lumbar spine allows 1 or more Congenital spondylolisthesis - Vary by grade
vertebral bodies to slip anteriorly - A person is born with lumbar facets that are oriented on a - Grade 1-2
Demographics sagittal rather than coronal plane  Central low back pain
- Congenital or isthmic forms may show up in adolescence or - Only a problem if physical activity challenges the facet joints  Tight hamstrings
young adulthood Isthmic spondylolisthesis  Spasm of lumbar paraspinal muscles
- Weightlifters, gymnasts, wrestlers, etc. have a high risk - A structural weakness at the pars interarticularis  Pain radiating into buttock and thighs
- Degenerative spondylolisthesis is mostly in adults over 40  Shows up during growth spurts with athletic activities - Grade 3-5
 Women > men; 5:1  Multiple micro fractures  Palpable shelf at lumbar spine
Etiology  Pain, loss of range of motion  Possible nerve compression
- Normal facet joints in the lumbar spine are on a coronal plane Degenerative spondylolisthesis  Possible cauda equina syndrome
 This prevents the higher bone from sliding forward - Mostly in mature adults Can look like peripheral artery disease, peripheral neuropathy
- If the pars interarticularis is weak, the bone may fracture - No damage to the vertebral arch Treatment
 These can heal with a false joint and hypermobility - Starts with arthritis, thinning discs at the facet joints - Mild pain relievers
 These can grow a bony bridge than lengthens the  Supporting ligaments become slack - Exercise to strengthen abdominal muscles
vertebral arch  Joint capsule stretches as the bone shifts forward - Massage therapy for back pain, hamstring tightness
 Fibrous bands may extend between the edges of the Traumatic spondylolisthesis - Back braces or corsets if necessary
injury - An accident or trauma damages the pars interarticularis - Possible surgery if necessary
Pathologic spondylolisthesis Massage Therapy Implications
- A complication of some other event Risks: acute pain and inflammation conjure indicates massage;
 Tumors from metastatic cancer instability must be addressed with careful positioning. Symptoms
 Infection of bone or joint capsule of numbness or reduced sensation should be pursued with a
 Complication of previous surgery neurologist
Benefits: chronic low back pain, spasm, tightness can all be
addressed with massage therapy
Options: avoid hyper-extending the back by using bolsters under
the abdomen when the client is prone, under the knees if client’s
supine
Research: many specialists are open-minded to non-invasive
interventions, including massage. A pedicle fracture has been
reported as an adverse effect of massage therapy
Spondylosis
Spondylosis
- Spondylosis is a form of generative arthritis that occurs in the spine - May be completely silent
- Mostly age related - Progressive loss of range of motion at the spine
- Affects vertebrae, discs, joints, and ligaments - Headaches
- Happens more frequently in the neck - Predictable pain if bone spurs press on nerve tissue
Demographics - May press on nerve roots or spinal cord
- Cervical spondylosis is very common in mature people  Myelopathy symptoms
- 90% of men over 50 years old, women over 60 years old  Loss of balance
 Not all have symptoms  Trouble walking
 (it is possible to show evidence of degeneration on imaging tests without having  Loss of bladder or bowel control
symptoms) Complications
Etiology - Usually not dangerous, some possible serious complications
- Similar to osteoarthritis, with some important differences  Compensation is the sine can cause more damage
- Analogy with synovial joint:  Nerve pain, radiculopathy
 Vertebral bodies = articulating bone  Secondary spasm
 Annulus fibrosis = capsular ligament  Blood vessel pressure
 Nucleus pulposus = synovial fluid  Myelopathy: spinal cord damage
- With age, shearing and compressive stresses affect spinal joints Treatment Medications
 Discs thin - Depends on symptoms and complications -NSAIDS
 Bone spurs develop on the vertebral bodies and facet joints - Anti-inflammatories for pain control -Narcotic or opioid drugs
- Bone spurs may grow in a place that causes pain - Bracing, movement, exercise -Muscle relaxants
- Vertical ligament may ossify - Massage therapy, acupuncture, hydrotherapy -Antiseizure drugs
 Anterior longitudinal ligament: diffuse idiopathic skeletal hyperostosis - Steroid injections -Injected steroidal anti-inflammatories
 Posterior longitudinal ligament - Surgery if necessary
 Ligamentum flavum Massage Therapy Implications
- Blood supply and embedded in the dura mater is vulnerable Risks: careless positioning may allow bone spurs to put pressure on nerves. Muscles may be guarding
for a good reason
Benefits: massage therapy can reduce pain and stiffness, improve quality of life, with cautions
Research: Massage therapy for neck pain can be effective; frequency of treatment may make a
difference
Sprains
Sprains
Definition Sprains vs. Tendinopathies Treatment
- Tears to ligaments - Ligaments have less capacity for elasticity - PRICE / POICE
Demographics  Poor stretch, rebound  Protection
- Very common  Leads to laxity, possible osteoarthritis  Optimal loading
 Estimated 20,000 per day to ankles alone - Sprains are more severe injuries  Ice
Etiology  Muscles and tendons are injured before ligaments  Compression
- Ligaments are linearly arranged collagen fibers - Ligaments swell more than tendons  elevation
 Link bone to bone  They are often contiguous with joint capsules - ultrasound
 Invested with fibroblasts Signs and Symptoms - exercise
 Invested with sensory neurons, especially - Acute injuries: - proprioceptive training
proprioceptor  Pain, heat, redness, swelling Medications
 Has impact on nearby muscle activity  Muscle splinting of unstable joint - NSAIDs
- Sprains are rips in ligament  May mask bone fracture, especially in the foot Massage Therapy Implications
 1st degree: mild; 2nd degree: moderate; 3rd degree: - Subacute: Risks: Lymphatic work may be helpful in the acute stage; other
rupture  Less inflammation massage is likely to be irritating. Watch for signs of bone fracture
- Healing process can be highly functional or not  Regained function Benefits: Mature sprains respond well to massage for mobility,
 Immobilized scar tissue can become dense and - Can happen at any synovial joint quality of scar tissue, and proprioceptive effects on nearby muscles
constrictive  Anterior talofibular is most common Options: With-fiber and cross fiber friction on affected ligament
 Reduced weight-bearing capacity (within pain tolerance) can help with rehabilitation
 Increased risk of re-injury Research: Massage is well-accepted and associated with good
outcomes for sprains. Work on the affected ligaments and nearby
connective tissue is recommended.
Temporomandibular Joint Disorder

- Temporomandibular joint dysfunction is a disorder of the muscles of mastication, the temporomandibular joints and associated structures
- Factors Contributing to TMJ Dysfunction
 Predisposition, tissue alteration and stress
 Intrinsic  genetic development of muscles, ligaments and bones
 Extrinsic  trauma to the neck, face or jaw
 Tissue alteration can occur to the skeletal, dental and neuromuscular structures
 Malocclusion, tooth loss, cranial bone misalignment, hypermobility, postural dysfunction, spasm, ischemia and trigger points, jaw clenching, bruxism, chewing gum
 Forward head posture  suboccipitals
 infra-, supra- and omo- hyoid, lateral pterygoid, temporalis
- opening lock or subluxation occurs when the condyle is anterior to the articular eminences; the condyle is unable to return posteriorly and the jaw cannot close
- closing lock occurs when the disc is displaced anterior and the condyle cannot reduce over the posterior portion of the disc into the disc depression; the jaw cannot open and there is premature dental contact on the same side of the disc displacement
- capsulitis  trauma, whiplash and prolonged dental procedure
- synovitis  joint effusion
- Symptoms
 May be unilateral or bilateral
 15-45 years or age, more common in women 5:1
 Triad of predisposition, tissue alteration (neuromuscular, skeletal and dental) and stress—jaw clenching or bruxism
 Postural dysfunction  forward head posture
 Fibromyalgia, osteoarthritis, and rheumatoid arthritis
 Early stage
 Crepitus
 Jaw pain (worse in morning)
 Headache
 Spasm
 Hypertonicity
 Decreased ROM
 Stiffness
 Later stage
 Can develop into contractures
 Degeneration of the disc, condylar head and articular eminence may occur
- Causes
 Imbalance in the muscles of mastication  hypertonicity, spasm, trigger points and abnormal joint mechanics
 Muscle overuse  chewing gum, prolonged yawning, pipe or cigar smoking; mouthguard or piece (music, scuba diving, etc.)
 Malocclusion  teeth loss, teeth grinding
 Cranial bone misalignment
 Postural dysfunction  hyperkyphosis and scoliosis, pelvic tilt, leg length discrepancy, ankle problems (pes planus or sprain)
 Increased stress  jaw clenching and bruxism (tooth grinding)
 Trauma  direct blow, whiplash, fracture, surgery, prolonged dental work, intubation, cupped hand sitting
 Sinus blockage or infection  improper breathing
 Joint pathology  hypermobility, capsulitis or synovitis leading to contractures, osteoarthritis and rheumatoid arthritis
- Special Tests
 Posture
 Palpation
 3-knuckle test
 Stethoscope (hearing for crepitus)
- Contraindications
 Do not compress over the carotid artery or carotid sinuses when treating the anterior neck muscle
 Do not use massage techniques on both SCM simultaneously
 Choked feeling
 Also infra and suprahyoid muscles
 Avoid deep work over the styloid process of the temporal bone –fragile structures
 Frictions are contraindicated if the client is taking anti-inflammatories or blood thinners
 Do not use techniques that compress the mandible superiorly against the TMJ
 Do not use latex gloves for intra-oral work if the client has a latex allergy
 Avoid using heavy or deep pressure when working intra-orally, as the muscles are delicate and often tender
 TMJ dysfunction may be a result of history of abuse, be MINDFUL
- Treatment Goals
 Reduce pain—decrease sympathetic nervous system firing
 Maintain local circulation
 Reduce inflammation and edema is present
 Fascial restriction
 Decrease tone/tensions
 Trigger points
 Increase mobility
 Reduce adhesions
 Strengthen weak muscles
- See 2 times a week for 2 weeks, reassessment, once a week for several months
Fascial Disorders
Periostitis & Compartment Syndrome
Compartment Syndrome
Definition Types of Compartment Syndrome - Chronic
- An injury or repetitive stress raises pressure inside a fascial Acute Compartment Syndrome  Pain, cramping, weakness, numbness
compartment - Sudden onset  At a predictable point in exercise
 Leads to damage of muscle and nerve tissue - Usually from  Subsides when exertion ends
- Usually in lower leg; can happen elsewhere  Crushing injury, fracture, penetrating injury  May be progressive, gets worse over time
Demographics  Burns, bites, stings Treatment
- Hard to estimate  Complications of surgery (arterial compression and - Acute
 Acute compartment syndrome is rare sudden release) - Chronic
o Can be a complication of fractures or crushing Chronic Compartment Syndrome Medications
injury - Usually from repetitive athletic activity - NSAIDs
Etiology - AKS exertional compartment syndrome Massage Therapy Implications
- Two forces maintain fluid balance in tight fascial - Increased circulation, muscle expansion with exercise Risks: Acute compartment syndrome is a medical emergency.
compartments:  Overwhelms balancing mechanism in tight Chronic compartment syndrome may respond well, but don’t
 Tissue pressure (rate and volume of incoming fluid) compartments exacerbate local inflammation
 Perfusion pressure (ratio of blood in arteries vs. in  Can look like shin splints Benefits: Chronic compartment syndrome may improve with
veins within the same space) Compartment Syndrome Locations massage therapy to help improve stamina.
- If tissue pressure > perfusion pressure, fluid can’t move out— - Usually in 1 of 4 compartments in lower leg Options: refer acute situations out immediately. When legs are
 Fluid pours in, gets trapped because veins and - Can be in foot, hand, forearms, etc. painful, lymphatic focus may be most appropriate. “Pin and pump”
lymphatics are compressed - At lateral thigh: meralgia paresthetica techniques may be helpful for lower leg muscles and fascial
 Damaged cells release pro-inflammatory chemicals, Signs and Symptoms sheaths before or after exercise.
and it gets worse - Acute Research: Massage may help to delay the onset of symptoms for
- Can lead to muscle and nerve death; by-products can cause  Sudden onset people with chronic compartment syndrome.
kidney damage  Tight, burning pain
 Passive stretching is very painful
 Palpable heat and induration
Compartment syndrome is a situation in which a fascial Acute compartment syndrome usually follows a trauma (a Risks: Any modality that manipulates soft tissues during an acute
compartment is under so much pressure that oxygen and nutrients crushing injury, arterial damage, a long bone fracture). It is phase of compartment syndrome may make a bad situation worse
can no longer reach cells. It can be acute, which is a medical extremely painful, especially when tissues are passively stretched, by drawing more fluid to an area that is already impacted.
emergency, or chronic and less severe. It usually happens in the and patients often report a tight, full feeling. Benefits: Massage and stretching (or both simultaneously) may
lower leg, but can occur in any fascially contained space. Chronic compartment syndrome is typically connected to a help to delay the onset of pain with chronic compartment
specific repetitive athletic activity. Cramping, pain, weakness and syndrome. Massage may also be an effect preventive measure for
numbness are all possible symptoms. Exercise makes it worse, but athletes at risk for this condition.
symptoms subside when the activity is suspended.
Dupuytren Contracture
Dupuytren Contracture
Definition Types of Fibromatosis Treatment
- AKA palmar fasciitis Plantar Fibromatosis - If treated early, may prevent progression
- Idiopathic shrinking of palmar fascia - AKA Ledderhose disease  Steroid, collagenase injections
- Type of fibromatosis - Just like Dupuytren contracture, on the sole of the foot  Needle aponeurotomy
Demographics Peyronie Disease - Surgery if fingers can’t move
- Mostly among middle-aged white men - Scar tissue develops under the skin on the shaft of the penis  Palmar incisions, skin grafts, physical therapy and
- History of Garrod Nodes massage
 Work with vibration - AKA knuckle pads - Recurs about 1/3 of the time
 Smoking - Deposits of connective tissue at PIPs of the hands Medications
 Alcohol use - Often related to repetitive trauma - Steroid or collagenase injections
 Diabetes Signs and Symptoms Massage Therapy Implications
Etiology - Begins with painless or mildly tender bump Risks: If nerves are damaged, sensation could be impaired. Steroid
- Idiopathic  Proximal to 4th digit on palmar side injection weaken tissues. Otherwise massage is generally safe and
- Proliferative phase:  May also involve 5th digit appropriate
 Myofibroblasts multiply; nodule develops, usually at - Nodule extends into a cord Benefits: If sensation is intact, massage may be helpful in slowing
base of ring finger  May take months or years the progression or helping rehabilitation after surgery
- Involutional phase: - Fingers are drawn into flexion, can’t be extended Research: Only 1 case study, but good results with instrument-
 Cord develops from nodule to PIP joints; other fingers - May be bilateral (usually worse on one side) assisted friction
may be involved - Often painless, slowly progressive
- Residual phase:
 Cords tighten, fingers bend into permanent flexion
Dupuytren contracture is an idiopathic shrinking and thickening of This is a painless condition that usually affects the ring and little Risks: Massage has no particular risks for Dupuytren contracture as
the fascia on the palm of the hand. fingers, pulling them into permanent flexion. long as it is performed within limits for pain tolerance.
Benefits: Massage may be useful to slow the progression of this
disease, or to help with the development of healthy and functional
scar tissue post-surgery.
- Dupuytren’s contracture is a contracture of the palmar fascia, resulting in a flexion deformity of the fingers
- MCP and IP joints of the 4th and 5th digits are most affected
- C is unable to extend digit voluntarily or by force
- Fascia is meant to absorb pressure and limit mobility of the skin, functions that are needed for the feet and hands
- 3 fibre directions in the palm: longitudinal, transverse and vertical
 Longitudinal and transverse counteract force when the hand is gripping something
 Longitudinal fibres (most superficial, palmaris longus to palmar creases and MCP and lateral phalanges) prevent shear forces (rotational forces) ex. gripping a baseball bat
 Transverse fibres (deeper layer, flexor tendon sheaths to thenar and hypothenar eminences) stabilize against transverse forces ex. sliding down a firepole
 Vertical fibres (skin to tendon sheaths and metacarpal bones, they bine fascia and skin of the hand) prevent shearing forces ex. degloving
- Begins with the shortening and fibrosing of the longitudinal fibres
- Palmaris longus is the ONLY muscle that tenses the palmar fascia
 Can be missing in European women, bilaterally more often than unilaterally
 Flexor carpi ulnaris acts as a flexor palmar fascia when absent and can still occur
- Palmar fascia produces new collage which forms into nodules causing intrinsic shortening of the fibres of the palmar fascia
 Cord-like adhesion but not in muscles, tendons or sheaths, or within the joint itself
- NO inflammation present
- Causes:
 Appears following an isolated injury to the hand, but the injury does not induce Dupuytren’s contracture
 Reason
 Intrinsic theory
 Shortening occurs due to changes within the palmar fascia itself leading to the nodules
 The extrinsic theory
 Changes in the dermis and palmar fascia
 Idiopathic in nature
 Heredity
 There is an association between Dupuytren’s contracture and epilepsy
 Other factors
 Hyperkyphosis, TOS, TP, reduced tissue health in C arms, increase sympathetic nervous system firing, tennis elbow, frozen shoulder, ulnar nerve lesions, shoulder-hand syndrome AKA reflex sympathetic dystrophy
- Symptoms
 Occurs in people between 40-50 (possibly earlier)
 Progressive, years, stages of remission and progression
 55% were affected bilaterally, 16% L and 29% R unilateral
 No correlation with dominant hand
 Palmar fascia is tender, thick ( may diminish) and nodular (near MCP is extended or IP flexed)
 Draws the finger into flexion
 Temperature changes in the fingers, particular 3-5 degrees C
 Increase is wrist flexor tone
 Latissimus dorsi and serratus anterior may contribute to compromised tissue health and pain
 Extension is not possible
 Contributing factors: hyperkyphosis and TOS lead to diminished tissue health
- Assessments
 Observation
 Hyperkyphosis  forward head posture
 Palmar aspect is assessed for nodules and fixing of the 4 th and 5th finger at the MCP and IP joints
 Tone in flexor tendons of the wrist
 Palpation
 Nodules
 Tenderness
 Differentiate between TP
 Increased tone in flexors of the wrist
 Also cervical muscles, rotator cuff and intrinsic muscles of the hand
 Cool to touch due to ischemia
 Testing
 ROM on cervical spine, shoulder girdle, elbow and wrist and joints of the hands
 Pain on extension may be present with leathery end feel on fingers
 Reduce muscle strength at wrist and fingers for flexors and extensors
 Special Tests
 Tabletop test
 Differential Diagnosis:
 Murphy’s Sign for dislocated lunate
 TOS: Adson’s, costoclavicular syndrome test, Wright’s hyperabduction test, etc.
- Contraindications
 Friction techniques are contraindicated if the client is taking anti-inflammatory medication
 If surgery, incision site must be completely healed prior to any massage fascial work or stretching of tissue
- Treatment Goals
 Hydrotherapy  wax or contrast to increase local circulation
 Pain reduction—decrease sympathetic nervous system firing
 Reduce TPs
 Maintain or increase ROM
 Stretching
 Increase local circulation/tissue health
- Frequency
 30 minutes once a week for 6 weeks
 May take several weeks to months to treat depending on severity and longevity
 Full extension may not be obtained
 The earlier the better
 May not focus unless QoL diminishes
Ganglion cysts
Hammer toe
Morton Neuroma
Morton Neuroma
Definition Contributing Factors Treatment
- Connective tissue sheath (perineurium) of common digital - Fascial restriction elsewhere in the leg may tug on the nerve - Non-invasive
nerves of toes becomes thickened - Muscle tightness at hamstrings, plantar-flexors can compress  Change footwear; orthotics; pads for metatarsal heads;
- Not technically a “neuroma” the medial and lateral plantar nerves stretching and massage therapy
- “perineural fibrosis” is more correct - High heels put pressure on metatarsal heads - Invasive
Demographics - Perineurium becomes thickened  Steroid injections; injections to kill the nerve; surgery to
- Numbers aren’t tracked - Other foot problems can make it worse: remove mass (high risk of complication)
- Appears to be common  Plantar fasciitis Massage Therapy Implications
- Women > men; 5:1  Bunions Risks: Don’t squeeze the metatarsal heads if this elicits symptoms.
Etiology  Hammer toe Otherwise massage therapy is generally safe.
- Common digital nerves supply motor control and sensation to  Pen planus/pes cavus Benefits: Massage may offer benefits, at least for the short run, as
the distal foot Signs and Symptoms long as the body work does not irritate the nerves
- Branches converge between metatarsal heads - Electrical shooting pain from ball of foot to lateral toes Options: Work to create space between the metatarsal heads,
- Can be compressed during toe-off  Usually between 3rd and 4th toe loosen and stretch the whole leg to undo fascial restrictions on the
- Usually with walking or weight bearing nerves
 Not at rest Research: 1 case report had good result for a client hoping to avoid
surgery
Plantar fasciitis
Plantar Fasciitis
Definitions Etiology Massage Therapy Implications
- Common condition of plantar fascia - Plantar fascia is susceptible to damage - Manage the tensions pulling on the plantar fascia
- Not technically “-itis” most of the time  Anatomic and biomechanical forces  Warming, massaging foot before walking
- More related to degeneration of collagen  May occur with growth of calcaneal bone spurs - Use feel cups, orthotics
Demographics  Not necessarily connected symptomatically - Night splint for the foot
- Most common cause of heel pain - Factors: - Corticosteroid injections
- Athletic and sedentary people  Running in worn down shoes  Used sparingly
- Women > men, 2:1  Being overweight - Proliferant or botulinum injections
Signs and Symptoms  Sudden change in activity levels - Extracorporeal shockwave lithotripsy
- Distinctive pattern:  Problems with gait, feet - Can take up to 18 months to resolve
- Acutely painful for 1st few steps after rest  Tight calf muscles Massage Therapy Implications
 Sharp, bruised feeling anterior to calcaneus on the  Complications of: Gout, rheumatoid arthritis, diabetes Risks: Avoid new cortisone injections until tissues are stables.
plantar surface or deep in the arch - Stressed, overused fibers fray and then: Otherwise, just avoid acute inflammation (which is not a big issue
- Pain subsides, but returns with fatigue  Fibroblasts enlarge with plantar fasciitis)
- Pattern repeats  Produce excessive, disorganized collagen Benefits: Massage is often suggested for foot and lower leg
Medications  Function is gradually lost muscles
- NSAIDs  Little or no inflammation (changes treatment options) Options: Work on intrinsic muscles, but also on those that manage
- Cortisone injection how the foot hits the ground
Research: Massage is often recommended, but hasn’t been
researched in this context.
Plantar fasciitis is a condition caused by repeated microscopic Plantar fasciitis is acutely painful after prolonged immobility. Then Risks: If the plantar fascia is acute inflamed (which is unlikely), local
injury to the plantar fascia of the foot. the pain recedes when the foot is warmed up, but comes back with deep massage should be delayed. Massage to the plantar fascia for
extended use. It feels sharp and bruise-like, usually at the anterior a client who has recently had a cortisone injection may increase
calcaneus. the risk of rupture.
Benefits: Massage can help release tension in deep calf muscles
that put strain on the plantar fascia; it can also help to affect the
quality of scar tissue at the site of the injury.
Pes Planus & Pes Cavus
Pes Planus, Pes Cavus

Definition Pes Planus Treatment
- Pes Planus = flat feet - Imbalance in arch stabilizers - Highly supportive shoes
- Pes Cavus: caved feet  Weakness in tibialis posterior tendon - Physical therapy to develop muscular balance
Demographics  Hypertonicity at peroneus muscles on the lateral side - Orthotics or braces if necessary
- … - In young children pes planus is normal; arches develop later - Surgery if necessary
Etiology Pes Cavus Medications
- Develops for several reasons: - Serious cases often a complication of underlying disorder -
 Congenital problem in shape of the bones  Malunion fractures Massage Therapy Implications
 Strength of ligaments  Compartment syndrome Risks: Pes cavus may be related to a serious underlying disorder;
 Trauma, malunion fractures  Charcot-Marie-Tooth syndrome make appropriate accommodations
 Imbalance between deep flexors and everters  Muscular dystrophy Benefits: Massage to intrinsic foot muscles and those of the legs
 Unsupportive footwear  Polio may improve the environment so that the arches can function
- When the foot lacks spring and mobility, shock absorption is  Cerebral Palsy more effectively
lost - Sudden onset, bilateral: may be due to nerve damage
 Leads to lots of other problems Signs and Symptoms
- If a person has problems with circulation and sensation, this - May be subtle until other tissues are disturbed by gait and
can become dangerous movement compensations
- Pes cavus is more likely to involve lateral foot pain, callus, ankle
instability
- Clinical 70 pg 517 Pes Planus
Neuromuscular Disorders
Carpal Tunnel Syndrome
Carpal Tunnel Syndrome

- A set of signs and symptoms connected to entrapment of the median nerve at the carpal tunnel - Tingling, pins and needles in nerve distribution
Demographics - Burning, shooting pain
- Most common peripheral nerve compression syndrome - Numbness
- Occupational hazard for people who do repetitive movements with their hands - Weakness
- Women > men; smaller carpal tunnels - Worse at night (especially sleeping with flexed wrist)
Etiology Treatment
- Source of CTS pain is debatable - Starts with wrist splint to keep the wrist neutral
 Pressure on the nerve - Anti-inflammatories as necessary
 Pressure impedes blood flow to the nerve - Steroid injections
- Factors: - Exercise
 Edema - Acupuncture, chiropractic, yoga, etc.
 Subluxation - Surgery if necessary
 Fibrotic build up  Can be open or endoscopic
Differentials  May not address the entirety of the problem if the nerve is irritated elsewhere as well
- Carpal tunnel syndrome can look like: Medications
 Neck injury, herniated disc - NSAIDs
 General nerve impairment - Steroid injections
 At thoracic outlet syndrome, elsewhere: multiple crush syndrome - Lidocaine injections
 Other wrist injuries Massage Therapy Implications
Risks: Avoid anything that exacerbates symptoms; otherwise massage therapy is safe and appropriate
Benefits: Massage may contribute to improved pain and function
Options: Focus on massage within pain tolerance for wrist, hand, arm and shoulder of the affected side
Research: Massage is consistently shown to be helpful to reduce symptoms and improve function
Carpal tunnel syndrome (CTS) is irritation of the median nerve as it CTS can cause pain, tingling, numbness, and weakness in the part of Risks: Any work that elicits symptoms must be modified to avoid
passes under the transverse carpal ligament into the wrist. the hand supplied by the median nerve. Complications or related irritation to the median nerve.
problems can also create pain the proximal wrist or forearm. Benefits: Depending on underlying factors, CTS may respond well to
massage that helps create more space for the median nerve to
function.
- Carpal tunnel syndrome (CTS) is a condition that results from the compression of the median nerve as it passes through
the carpal tunnel at the wrist. This results in numbness and tingling in the median distribution—that is, the lateral 3 and a
half of digits
- Most common entrapment syndrome in the arm, approx.. 1% of the pop or higher depending on demographic
- Related to highly repetitive flexion and extension actions of the wrist
- Aggravated by movement which causes pain
 Enough to wake a person from sleeping
- Thenar muscle wasting can lead to weakness and clumsiness of the thumb and fingers
- If CT is present with another proximal compression it is referred to double crush syndrome
- Anatomy
 Carpal tunnel is distal to the wrist creases where it blends with the palmar fascia
 Floor is the carpal bones
 Roof is the flexor retinaculum aka. transverse carpal ligament
 Attached to the pisiform and hook of the hamate bone on the ulnar side
 Attaches to the scaphoid tubercle and trapezium on the radial side
 Cutaneous branch does NOT travel through the carpal tunnel
 Structures that travel through the carpal tunnel are:
 The median nerve
 4 tendons of the flexor digitorum superficialis
 4 tendons of the flexor digitorum profundus
 Tendon of the flexor pollicis longus
- Condition is often unilaterally with dominant hand
- Men and women equally, however women physiology can effect it
- Massage therapy focuses on reducing local edema and addressing increased muscle tone as well as adhesions and trigger points
 Also posture for wrist and arm biomechanics
- Some causes of CTS are idiopathic
 (chronic) Increase in the size of the contents through the tunnel
 Repetitive actions (wrist flexion and extension)
 May lead to edema of chronic fibrosis and thickening of the tendons
 Thickening of the retinaculum due to scar tissue/repeated trauma
 Systemic conditions that result in edema and fluid retention or connective tissue degeneration (ex. diabetes, hypothyroidism, rheumatoid arthritis and pregnancy)
 (chronic) Decreased canal space
 Bony callus after a fracture of the carpal bone or distal radius
 Space-occupying lesions such as a ganglia, lipomas or cysts
 Bony changes that occur with rheumatoid arthritis
 Acute
 Fracture or dislocation (especially the lunate)
 Infection
 Flare up of rheumatoid arthritis
 Repetitive wrist actions
 Hematoma (with hemophilia or anticoagulants)
 Vitamin B6 deficiency
 Familial tendency
- Pronator Teres Syndrome and Median Nerve Compression
 The median nerve is compressed at the level of the proximal attachment
 Compression from the tendon may be thickened due to local trauma
 Gradual, insidious onset
 Person experiences aching (tiredness or heaviness) in the anterior forearm and numbness in the thumb and index finger and some weakness in the thenar muscles
 Dull to sharp pain in the anterior forearm with repetitive elbow movement rather than wrist movement
 Tenderness found at the proximal attachment
 Pain on ARROM on pronation
 NO night symptoms
- Repetitive Strain Injury (RSI)
 Often associated with computer work
 Voice activated computers are advised  RSI of the larynx
 Includes: tendinitis, tenosynovitis, carpal tunnel and thoracic outlet syndromes and TP
 Chronic pain and disability, if sever can lead to permanent median nerve damage
- Symptom Picture
 Unilateral presentation, usually dominant hand
 Numbness and tingling in the median distribution
 Nocturnal dysthesia (waking up in pain), may be due to the venous stasis or persistent compression from sleeping with the wrists flexed
 Local pain on wrist activity  can continue to the forearm, elbow and rarely the shoulder
 Space-occupying lesions or bony cysts may be present
 Will often shake, massage or exercise the hand for relief of symptoms
 Sometimes placing the hand under cool or warm water
 Person is distressed over the loss of function or inability to work
 Swelling or edema may be present
 Increases during physiological womanly times (pregnancy, menstruation, menopause)
 Tissue texture of the forearm may be boggy and fibrous from metabolic waste
 Mottling of the skin or sweating of the hand
 Hypertonicity from overuse or TP in the muscles of the hand
 Subscapularis and scalenes refer to the wrist, palm and lateral digits
 Adhesions can develop at the flexor retinaculum as well as the tendons
 From overuse
 Also secondary to rheumatoid arthritis
 Atrophy of the thenar muscles during progression
 Clumsy movements of the thumb and index finger
 Buttoning a shirt or holding a mug
 Worse in the morning
- Assessments
 C demonstrates actions
 Posture and Palpation
 Unilateral symptoms, generally dominant hand
 Splint may be worn
 Inflammation or edema in the hand and wrist, more diffuse over the hand and forearm
 Later stage, thenar muscle atrophy (possible tissue health decrease)
 Weakness of the thenar muscles when writing
 Tenderness over the carpals and median nerve
 Tissue texture may be boggy at the wrist
 Forearm muscle are dense due to accumulation of metabolic waste
 Hypertonicity and fascial restrictions of the forearm muscles due to overuse
 TP in muscles
 Range of Motion
 AROM and PROM reveal decrease range in flexion and extension, possibly ulnar deviation
 End feel if often empty
 ARROM abductor pollicis brevis is positive
 Special Tests
 Phalen’s and reverse Phalen’s test are +
 Cyriax’s variation of Phalen’s
 Tinel’s Sign + (be caution of false positives)
- Differentiating Sources of Wrist Pain
 C6 and C7 radiculopathies
 Disc lesions
 Different due to overall muscle weakness (biceps brachii and triceps brachii)
 DTR are decreased
 Neck pain and pain in movement, decreased with relaxation
 Night pain is rare
 Thoracic outlet syndrome
 R/O
 Muscle wasting of the hypothenar not thenar
 Radiating is over the pinky and ring finger, not the thumb and 3 digits
 Pronator teres syndrome
 Pain in anterior forearm and elbow movement
 Tenderness upon palpation
 No night pain
- Contraindications
 Frictions are not performed if carpal tunnel syndrome is the result of rheumatoid arthritis due to joint instability, decreased tissue health (ex. diabetes), if edema is present, or anti-inflammatories are being taken
 Vigorous joint play is not used if rheumatoid arthritis, hypermobility or during pregnancy
 No local massage is performed until 10 days after a corticosteroid injection
- Treatment Goals
 Positioning
 Prone allow access to treat and r/o subscapularis TP
 Side-lying possibly for rotator cuff muscles
 Supine if edema is present
 Support arm during treatment
 Hydrotherapy reflects stage of condition
 Cold for acute, inflamed or edematous tissue as well as after deep techniques
 Contrast for creating a vascular flush of the hand and forearm
 Heat, especially wax, before fascial techniques and friction, for trigger points
 Reduce edema
 Decrease adhesions
 Reduce trigger points
 Reduce stress
 Maintain range of motion
 Improve tissue health and circulation to remove metabolites
- Self-Care
 Ergonomics for computer work
 Hydrotherapy (contrast particularly)
 Stretch for shortened muscles
 Instruct in self-massage
 Encourage relaxation
 Refer client is symptoms aren’t alleviated
- Treatment Frequency and Expected Outcome
 45-60 minute treatments
 More relaxation
 30 minutes for a more focused treatment
 Twice a week for a few weeks initially then decrease to once a week for 4 weeks
Disc Disease & Degenerative Disc Disease & Hernia
Disc Disease
Definition Types of disc Problem Complications
- An umbrella term for problems with the nucleus pulposis Herniated disc - Pressure on spinal cord:
and/or the annulus fibrosis of intervertebral discs - Bulge  Cauda equina syndrome
- Parts of the disc extend beyond normal boundaries  The entire disc protrudes symmetrically outside its  Risk of permanent damage
- Most symptoms associated with nerve pressure normal boundaries Treatment
- AKA: introvertebral disc degeneration, IDD - Protrusion - Requires accurate diagnosis
Demographics  The nucleus pulposis extends outward at a specific  Can look like, accompany fractures, ligament injuries,
- Up to 80% of the population will have low back pain at some location etc.
point - Extrusion - Goals:
- Disc disease may be a common contributor  A small bit of nucleus protrudes, with a narrow  Relieve pressure so disc can recede if possible
- Factors include overuse and genetics connection back to the body - Rest, traction, physical therapy and exercise, education on body
Etiology - Rupture mechanics
- Structure of a health disc:  The nucleus pulposis bursts and leaks contents into the - Injected papain
 Outer wrapping of annulus fibrosis surrounding area - Discectomy
 Made of concentric rings: Degenerative disc disease Medications
 Stronger when stretched - Small, cumulative tears of the annulus - NSAIDs
 Weaker when loose - Decreased disc height - Narcotic analgesics
 Soft center of nucleus pulposis - Dehydration of the nucleus - Drugs for nerve pain
 Should be roughly spherical - May eventually put pressure on nerves or spinal cord - Injected steroidal anti-inflammatories
- Cartilage endplates attach to adjoining vertebral bodies - May eventually atrophy, leading to spinal fusion - Injected papain
- Discs can resist compressive and shearing forces Internal Disc disruption - Inject lidocaine
- With age… - Nucleus protrudes into the annulus but stays within boundaries -Muscle relaxants
 Nucleus becomes tinner and dryer of the disc Massage Therapy Implications
 Annulus must bear more weight Endplate junction failure Risks: Work with the health care team, avoid acute inflammation
 Risk for cracks and fissures - Avulsion of cartilage from vertebral bodies and positioning that exacerbate symptoms; respect muscle
 Cartilage and plates may ossify - Bone fragments within discs splinting
 Closely aligned to spondylosis (New approach to spine problems) Benefits: Massage therapy is generally well accepted and effective
- Causes of disc injuries: Signs and Symptoms for low back pain
 Motor vehicle accident or other major trauma - Disc degeneration may not cause pain Options: Use bolsters or cushions to avoid hyperextension of the
 Lifting – twisting injury forces nucleus toward the - Symptoms are related to nerve pressure and/or inflammation back
weakest point of the annulus or, causes the annulus to - Pain may be intermittent Research: Massage therapy is generally well-accepted as an option
crack - Local and radicular pain to try with disc problems, but the research in its favor is not yet
 Inflammatory response contributes to pain - Specific muscle weakness strong
- Bulge is usually posterolateral - Paresthesia
- Direct posterior bulge could cause cauda equina syndrome - Reduced sensation
- Numbness
- Degenerative Disc Disease - Clinical 70 pg. 617
Myofascial Pain Syndrome
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome

Definition Contributing Factors Treatment
- Neurovascular entrapment - Muscle imbalance - Analgesics
 Nerves of the brachial plexus  Scalenes and pectoralis minor vs. rhomboids, trapezius, - Physical therapy
 Blood vessels running to or from the arm neck extensors - Surgery if necessary
- Three sites: - Connective tissue bands Medications
 Between media/anterior scalenes  Bands can grow at attachment points of the scalenes - NSAIDs, opiates
 Between clavicle and 1st rib - Cervical ribs - Muscle relaxants
 Under coracoid process  Transverse process of C7 grows longer than usual, - Anti-seizure drugs, antidepressants for pain
Demographics impedes other structures (cervical rib) - Anticoagulants for risk of thromboembolism risk
- Most frequent in people who: Differentials Massage Therapy Implication
 Carry heavy loads - It is important to have an accurate diagnosis Risks: If symptoms are due to anatomical features, massage won’t
 Do repetitive movements with arms and shoulders - TOS can look like: change them; careful positioning and awareness of medications are
 Spend time with arms in the air  Cervical subluxation important
 Women > men (smaller structures)  Spondylosis Benefits: Massage with postural and movement education can help
Etiology  Rib misalignment when symptoms are related to muscular imbalances or fascial
- Brachial plexus = C5-T1  Nerve entrapment elsewhere restriction
 If any part is compressed between the intervertebral  Lung tumor Options: Focus on shoulder girdle, scalenes, postural muscles of the
foramina and their final destination, symptoms can  Aneurysm/thrombus neck
develop Signs and Symptoms Research: Case studies suggest that massage therapy may be
 Subclavian vein, axillary artery also at risk - Shooting pain, numbness, weakness, tingling helpful for weakness and pain
- Neurogenic TOS is only nerve compression - Feeling of fullness (satiety)
- Vascular TOS is only blood vessel compression - Feeling of coldness
- Disputed TOS means the points of compression are not - Difference in the color or temperature of arms
identified - Exacerbated by cold
- Thoracic outlet syndrome (TOS) is a condition that involves the compression of the brachial plexus and its accompanying artery between the anterior and middle
scalene muscles (anterior scalene syndrome) or between the coracoid process and the pectoralis minor muscle (pectoralis minor syndrome) or between the clavicle
and the first rib (costoclavicular syndrome)
- Compression of these points causes numbness and tingling of the fourth and 5 th digits and on the ulnar side of the hand and forearm
- Found that many people thought to have TOS actually had carpal tunnel syndrome (CTS)
 Most common nerve compression syndrome
- Trigger points in the muscles contribute to muscle hypertonicity leading to compression
- Diagnosing TOS is a process of eliminating other likely compression syndromes such as CTS and ulnar compression at the elbow
- Brachial plexus is composed of nerve roots C5-C8 and T1
 Travels with the subclavian artery between the anterior and middle scalene (interscalene space)
 Then goes below the clavicle (costoclavicular space)
 Travels under the pectoralis minor (sub-pectoral space)
- Begins insidiously and progresses slowly
- Cause of the syndrome include:
 Internal (bony callus, cervical rib) or external compression (crutches)
 Prolonged poor positioning
 Poor posture
 Hyperkyphosis and scoliosis
 Hypertonicity and TPs
 Systemic immune or metabolic disorders
 Rheumatoid arthritis, diabetes and hypothyrdoism
 Trauma
 Inflammation and subsequent scarring, ex. whiplash
 Joint subluxation
 Cervical spine
 Pregnancy
- TOS cause neuropraxia (loss of conduction at the compression) with no degeneration
- Nerve compression symptoms include:
 Pain, sensory loss, motor weakness (paresis)
- Vascular compression results in trophic changes in the tissue
- Special Tests are used to differentiate between the structures and which system it impinges on
 Radial pulse and pain
 These tests can yield false positives
 Could be possible that combination of system compressions in different spots
 Neurovascular bundle is compressed in more than 1 location AKA double crush syndrome
- 60% of shoulder girdle compression and 25% in carpal tunnel compression
- Anterior and Middle Scalene
 Medial cord of the plexus is most vulnerable to compression since it lies in an inferior position passing through the scalene triangle making up the ulnar nerve symptoms
 TP can be activated by heavy lifting and carrying as well as overuse of the respiratory muscles (like extreme coughing from bronchitis, pneumonia, asthma and
emphysema
- Costoclavicular
 Dependent on the shoulder position or anatomical anomalies
 Abduction of the arm, retraction of the scapula and elevation of the first rib with inspiration will lead to narrowing of the space
 Subclavian trigger points refer to the lateral arm, bypassing the elbow and wrist then continue down the dorsal and palmar sides of the hand and the thumb, index and middle finger
 Fracture (particular a poorly set), marked bony callus, drooping shoulders, chronic respirator pathologies (emphysema, osteoarthritis)
- Pectoralis Minor Syndrome
 Aka hyperabduction syndrome because it occurs with raising of the arm into hyperabduction and external rotation
 Happens during painting or playing an instrument like a violin or flute, sleeping, rib fracture, dislocation or crush trauma
 Pec minor trigger points refer pain primarily over the anterior deltoid and pectoral area, possibly subclavian and travels down the medial arm to the 3 rd and 4th fingers
 Raynaud’s disease like symptoms appear in 1/3 of people
 Edema could be present
- Symptom Picture
 Can be unilateral or bilateral
 Can be neurological compression (brachial plexus) or vascular compression (subclavian artery and vein and lymphatic vessels) or both
 Neuronal Compression
 Paresthesia and hyperesthesia on the ulnar side of the hand, fingers and possibly forearm
 C8 to T1
 Intrascalene triangle
 Pain develops subsequently
 Diffuse, aching or throbbing pain in the upper limb shoulder, forearm and hand
 Less likely to be in neck and chest
 Less likely to present with headache
 TP in scalenes, pec minor and subclavian refer down the arms
 Latissimus dorsi, serratus anterior and posterior can mimic TOS pain
 Pain is triggered by letting arms hand down, carrying or lifting heavy objects of raising the arm above the head
 Relieved by lying down
 Gradual increase in motor weakness of the hand and fine motor skills
 Clumsiness
 C8 and T1 control intrinsic hand muscles
 Atrophy in the hypothenar and interossei muscles
 Thenar muscle occasionally
 Vascular Compression
 Ischemic changes and compromised circulation cause pain, pallor (possibly cynosis) and coldness
 May present similar to Raynaud’s phenomenon
 May develop to emboli or gangrene in fingertips (nails and skin)
 Can result in edema, especially in dorsal surface of hand
 May present with stiffness and puffiness on waking up
- Assessments
 Difficulty in gripping and performing other fine motor skills
 Posture and Palpation
 Drooping shoulders
 Hyperkyphosis or scoliosis
 Muscle wasting of the intrinsic hand muscles, hypothenar and interossei muscles
 Circulatory compromise results in pallor of the fingers, edema of the hand (severe cases: necrosis of the fingertips)
 Tenderness, hypertonicity and TP in the scalenes, pectoralis minor and subclavius muscle
 Fascial restrictions in the neck, shoulders and upper arm
 Hand may be cold
 Range of Motion
 AROM and PROM of the shoulder and neck show decreased movement
 Specifically the anterior scalene in rotation and lateral flexion accompanied by pain
 Special Tests
 Adson’s  anterior scalene
 Travell’s variation  middle scalene
 Scalene cramp and scalene relief tests
 Costoclavicular and Eden’s tests  1st rib and clavicle
 Wright’s hyperabduction  pectoralis minor compression
 Pectoralis minor length test  shortness
 Upper limb tension test  differentiating from cervical nerve roots to peripheral nerve roots
- Differentiating Conditions with Arm Symptoms
 Cervical spine spondylosis, radiculopathy and tumors
 DTR are + for these conditions
 Spurling’s test + for facet joint irritation
 ULTT is + for nerve root and peripheral nerve compression
 Raynaud’s disease
 Sensitivity to cold, not with TOS
 Carpal tunnel syndrome
 Thenar side of the hand not with TOS
 Ulnar nerve compression
 At the elbow or Guyon’s canal/tunnel will be + for paresthesia but not atrophy
 Tendinitis
 Osteoarthritis
- Contraindications
 Do not place deep moist heat over the neck or anterior chest if the client has hypertension or atherosclerosis in the neck vasculature
 Do not perform muscle stripping or aggressive techniques in these circumstances
 Avoid frictions if anti-inflammatories are being taken
 Modify techniques and pressure if the tissue is fragile
 Avoid aggressive mobilizations if degenerative disc disease, rheumatoid arthritis or a cervical rib is present
- Treatment Goals
 Positioning
 Hyperkyphosis place towel under the back to open chest
 Side-lying is most efficient to treat, especially for pectoralis minor opening up the costoclavicular space
 Hydrotherapy
 Deep moist heat on the lateral neck, shoulder or pectoralis minor
 If edema is present, cool applications are appropriate
 Contrast hydrotherapy to improve circulation
 Treat the entire shoulder girdle and neck and any postural contributors
 Address compensatory structures
 Decrease pain; decrease sympathetic nervous system firing
 Decrease compression of the neurovascular bundle
 Stretch shortened muscles
 Decrease trigger points
 Reduce edema IF present
 Improve tissue health and circulation
- Self-Care
 Shower before for more stretch
 Moist heat, reduce air conditioning
 Strengthen upper traps and levator scapulae (shoulder shrug), and rhomboid (retraction of scapula)
 Recommend that backpacks should have padding or fall on the acromion
 To relieve any of these compression it is recommended for 6 months to a year for massage at 45-60 minutes twice a week for 2 weeks for initial treatments then once a week
 If symptoms persist surgery may be performed
Sciatica
- Sciatic nerve is the strongest and longest of the peripheral nerves
- Provides motor to supply to the hamstrings lower leg and foot
- Provides sense to the posterior leg and most of the anterior and posterior leg and foot
- Sciatic nerve L4-S1 and divides into the tibial and peroneal nerves
 Tibial nerve is the larger of the 2
 Tibialis divides into medial and lateral plantar nerves
 Supply intrinsic foot muscles and sensory to the heel of the hoot
 Peroneal forms the sural nerve supplies skin of the lateral and posterior part of the inferior third of leg and lateral side of foot
 peroneal nerve splits into superficial and deep peroneal nerves
 superficial branch supplies skin on the distal anterior surface of the leg and most of the dorsal surface of the foot and toes
- Leaves the sacral plexus through the greater sciatic foramen and under the piriformis muscle
 Then deep to the adductor magnus
 At the popliteal fossa splits
 tibial travels down between the popliteal fossa and is found posterior the medial malleolus and Achilles tendon
 peroneal nerve passes the popliteal fossa and travels around the head of the fibula
 deep continues down to the lateral malleolus to the dorsal surface of the foot between the peroneal muscles
- Muscles Innervated by
 Sciatic
 Hamstrings
 Half of adductor magnus
 Tibial
 Gastrocnemius
 Plantaris
 Popliteus
 Soleus
 Tibialis posterior
 Flexor digitorum longus
 Flexor hallucis longer
 Intrinsic foot muscles: flexor digitorum brevis, flexor hallucis brevis, abductor hallucis, abductor digit minimi, adductor hallucis, lumbricals and interossei
 Personal
 Extensor digitorum longus
 peroneus longus, brevis and tertius
 tibialis anterior
 Extensor hallucis longus
 Extensor digitorum brevis
 Extensor hallucis brevis
- Cause of the lesions of the sciatic nerve are:
 Fractures
 Pelvis, femur, tibia or fibular head or ankle (inversion)
 Dislocation
 Hip, knee or ankle
 Iatrogenic reactions
 Injections in the gluteal muscles
 Hip surgery
 Meniscal repair
 Improper positioning during surgery or traction post-surgery
 Compression from internal sources
 Piriformis
 Flexor retinaculum in the foot causing tarsal tunnel
 Ganglion
 Morton’s foot structures
 Compression from an external source
 Cast of splint, crossing legs, prolonged squatting
 Can result in 1st degree neuropraxia or 2nd degree axonotmesis
 Trauma
 Contusion in the gluteals
- Symptoms
 Sciatic = Foot drop
 Paralysis of the dorsiflexor and elevators of the foot
 Causes limp plantar flexion and inversion
 Person lifts leg to walk  steppage gait
 Tibial = claw toe deformity
 Hyperextension at the MTP joints and flexion of the IP joints
 Because the extensor digitorum and hallucis brevis are still intact through the personal nerves
 Sciatic = Muscle wasting of hamstring
 Personal = muscle wasting anterior leg may be flaccid
 Tibial = muscle wasting posterior leg and foot
 Injuries from infection or pressure sores
 Tibial = severe trophic changes and edema in the sole of the foot and toes
- Differential Assessment
 L4-L5 radicular lesion  disc prolapse
 Results in weak inversion and tibialis posterior muscles
 Sensory dysfunction in the outer leg in L5 over the entire aspect of the outer leg and most of the dorsum of the foot
- Sensory Dysfunction
 Tibial
 Sensation in the posterior leg, heel and sole of foot including toes
 Peroneal
 Sensation on the lateral and anterior surface of the lower leg and foot Medial to the medial malleolus along the edge of the foot BUT NOT the toes
 Anesthesia is experience on the dorsal surface of the foot between web space from the big toe and 2 nd digits
Handout – Sciatica
- The sciatic nerve is a thick and long nerve in the body

- It passes alongside or goes through the piriformis muscle, goes down the back of the leg, and eventually branches off into smaller nerves that end in the feet
- Nerve compression can be caused by spasm of the piriformis muscle
- What is Sciatica?
 Sciatica refers to back pain caused by a problem with the sciatic nerve
 This is a large nerve that runs from the lower back down the back of each leg
 When something injures or puts pressure on the sciatic nerve, it can cause pain in the lower back that spreads to the hip, buttock, and leg
 Up to 90% of people recover from sciatica without surgery
- Symptoms of Sciatica
 The common symptom is lower back pain that extends through the hip, buttock and down the leg
 The pain usually affects only one leg and may get worse when sitting, coughing or sneezing
 The leg may also feel numb, weak or tingly at times
 The symptoms of sciatica tend to appear suddenly and can last for days or weeks
- Sciatic or Other Back Pain?
 Up to 85% of Americans experience some type of back pain during their lives
 This doesn’t always involve the sciatic nerve
 In many cases, back pain is the result of overextending or straining the muscles in the lower back
 What most often sets sciatica apart is the way the pain radiates down the leg and into the foot
 It may feel like a bag leg cramp that lasts for days
- Who Gets Sciatica?
 Most people who get sciatica are between the ages of 30-50
 Women may be more likely to develop the problem during pregnancy because of pressure on the sciatic nerve from the developing uterus
 Other causes include herniated disk and degenerative arthritis of the spine
- Cause: Herniated Disk
 The most common cause of sciatica is a herniated disk
 Disks act like cushions between the vertebrae of the spine
 These disks get weaker through aging and become more vulnerable to injury
 Sometimes the gel-like center of a disk pushes through its outer lining and presses on the roots of the sciatic nerve
 About 1/50 people will get a herniated disk at some point in life
 Upper to 25% will have symptoms that last more than 6 weeks
- Cause: Spinal Stenosis
 Natural wear and tear of the vertebrae can lead to a narrowing of the spinal canal
 This narrowing called spinal stenosis, may put pressure on the roots of the sciatic nerve
 Spinal stenosis is more common in adults over age 60
- Cause: Spinal Tumors
 In rare cases, sciatica may result from tumors growing inside or along the spinal cord or sciatic nerve
 As a tumor grows it may put pressure on the nerves that branch off the spinal cord
- Cause: Piriformis Syndrome
 The piriformis is a muscle found deep inside the buttock
 It connects the lower spine to the upper thighbone and runs directly over the sciatic nerve
 If this muscle goes into spasm, it can put pressure on the sciatic nerve, triggering symptoms of sciatica
 Piriformis syndrome is more common in women
 A Fat Wallet Can Trigger Piriformis Syndrome
 Condition can affect men who wear their wallet in the back pocket of their pants
 This puts chronic pressure on the piriformis muscle and can aggravate the sciatic nerve over time
 Can avoid this problem by keeping the wallet in a front pocket or jacket
- Cause: Sacroiliitis
 Is inflammation of one or both of the sacroiliac joints, the spot where the lower spine connects to the pelvis
 Sacroiliitis can cause pain in the buttock, lower back and may even extend down one or both legs
 The pain can worse with prolonged standing or climbing stairs
 Can be caused by arthritis, injury, pregnancy or infection
- Cause: Injury or Infection
 Include: muscle inflammation, infection, or injury, such as a fracture
 In general, any condition that irritates or compresses the sciatic nerve can trigger symptoms
 In some cases, no specific cause of sciatica can be found
- Diagnosing Sciatica: Exam
 To determine whether you have sciatic, your therapist will ask you how the pain started and where exactly it is located
 You may be asked to squat, walk on your heels or toes, or raise your leg without bending the knee
 These muscle tests can help the therapist determine if it is the sciatic nerve that is irritated
 If involved right away refer to their doctor
- Sciatica Relief: Ice and Heat
 There are steps taken at home to ease the pain of sciatica
 Heating pad or ice pack may be helpful
 Apply the heat or ice for about 20 minutes every 2 hours
 Experiment to see which provides more relief, or try alternating between the 2
- Sciatica Relief: Medication
 OTC pain relievers can provide short-term relief
 Acetaminophen and NSAIDs, such as aspirin, ibuprofen, and naproxen are options
 Doctor may give corticosteroid injection to reduce inflammation
- Sciatica Relief: Stretching
 While sciatica is healing, try to remain active
 Motion can actually help reduce inflammation and pain
 A physical therapist can show how to gentle stretch the hamstring and lower back
 Practicing tai chi or yoga can help stabilize the affected area and strengthen your core
 Depending on medical condition, exercise might not be recommended
- Sciatica Relief: Surgery
 If due to a herniated disk, and it’s still causing severe pain after 4-6 weeks
 The surgeon will removed a portion of the herniated disk to relieve the pressure on the sciatic nerve
 About 90% of patients get relief from this type of surgery
 Other surgeries relieve spinal stenosis
- Sciatic Rehab
 After back surgery, generally need to avoid driving, lifting, or bending forward for about a month
 Doctor may recommend PT to help strengthen the muscles in the back
- Complementary Therapies
 Evidence that acupuncture massage, yoga and chiropractic adjustments can relieve typical lower back pain
- Preventing Sciatica
 Increasing chance on sciatica is experienced
 Avoid back injuries that may lead to sciatic
 Exercise regular
 Maintain good posture
 Bend at the knees to lift heavy objects
Piriformis Syndrome
- Piriformis syndrome is the compression of the sciatic nerve by the piriformis
- Pain refers down the sciatic nerve
- May refer to lumbar spine, gluteals or at a distal point
- May present with TP referral pattern
- Piriformis insert on the anterior surface of the sacrum (S1 to S4) and runs in a horizontal direction to attach to the medial superior aspect of the greater trochanter
- Functions:
 Restrain rapid or vigorous internal rotation of the hip
 Running or stance phase of walking
 External rotation of the hip
 Extended or neutral
 Horizontally abducts the hip
 Even when flexed to 90 degrees
 Internally rotates the hip
 When fully flexed
- Greater sciatic foramen
 Formed by osseous greater sciatic notch of the ilium laterally, the sacrospinal ligament inferiorly and the piriformis muscle superiorly
- Any contraction or shortening will result in compression
 Tension
- Usually travels underneath but 10-20% it travels through the piriformis
 18% have 2 bellies
- Piriformis TP located just lateral to the border of the sacrum and under 1/3 rd of the way medial to the greater trochanter
 Refers to SI region, buttock, over the hip and extending over the proximal 2/3rds of the posterior thigh
 Continues to the calf and sole of the foot
- Causes of piriformis syndrome are:
 Anomalies in the course of the nerve
 Behind or in the muscle
 Direct and indirect trauma
 Fall on buttock, MVA  inflammation and ischemia and spasms resulting in scar tissue, adhesions thus TP
 Stopping oneself from slipping while walking
 Overloaded muscle
 Inflammation or degenerative changes
 Fascia or adjacent joints dysfunction
 Hip replacement
 Narrow foramen
 Overuse
 Repeated bending and lifting, forceful rotation, squatting, strong lengthening contraction to restrain from internal rotation, jogging and using a step machine
 Postural and positional concerns
 Hyperpronation increases internal rotation and adduction during walking
 Flexion contractures or hyperlordosis
 Tight or stretched muscles in the buttock
 Pregnancy due to COG shift
 Shortened position for long periods of time
 Driving a car for prolong periods with the foot on the gas
 Anything that aggravates a TP will cause shortening
 Even a WALLET
- Medical Treatment
 Corticosteroid injections
 PT
 Surgery
 Sectioning of the tendon near the insertion
 Massage therapy reduces compression through the TP and decreasing hypertonicity
- Symptoms
 Unilateral
 Pain
 Increases by sitting or prolonged hip flexion, adduction and medial rotation
 Especially on rising from seated position
 Aggravated by activity, internal rotation, especially in the muscle is split
 Decreased pain in external rotation of the hip
 Paresthesia in the posterior thigh to the calf and sole of the foot
 Possible gluteal and SI pain
 Low back
 May lead to an ataxic gait or drop foot
 In perineal and inguinal pain as well as dyspareunia (painful sex for women) and impotence in men
 Possible gluteal atrophy
 Tissue changes in the skin and swelling of the lower limb
 Weakness in performing abduction, flexion and internal rotation
 SI joint dysfunction
 Shortening
 Tension
 Compression
- Assessments
 Observation & Posture
 Guarding of the limb
 Difficulty with prolonged sitting or standing
 Shifts positions frequently or crosses their legs or routinely gets up and sits down
 Torsion of the hips (SI dysfunction) and hyperlordosis
 Supine
 Excessive external rotation of the leg
 Swelling of the lower limb
 Rarely hypotrophy of the gluteals
 Palpation
 TP palpation
 May be present in the gluteals
 Hypertonicity
 If hyperlordosis, iliopsoas, quadriceps and QL are hypertonic and have TPs
 Tenderness upon palpation
 Adhesions in and around site
 Rarely hypotrophy of gluteals
 Gait
 Ataxic-like gait due to pain
 Range of Motion
 AROM & PROM
 Decreased internal rotation accompanied by pain
 ISO
 Weakness and pain
 Special Testing
 Hibbs Test / Piriformis Length Test
 Pace abduction test
 Differential Testing
 Valsalva’s, Kemp\s, Kernig’s, Slump, SLR, DTR, toe walking (S1) or heel walking (L5) or one-sided deep knee bend (L3-4)
- Differentiating Sources of Radiating Buttock Pain
 Compression of the nerve at the lumbar spine
 Lumbar spinal stenosis
 Facet joint irritation
 Inflammatory arthritides
 Ankylosing spondylitis
- Contraindications
 Do not massage locally for 10 days after a corticosteroid injection
 Avoid compression of the sciatic nerve when massaging buttock
 Elbow pressure at lateral border of sacrum
 Do not perform frictions if on anti-inflammatories
 Joint play along with hip and sacral mobilization are avoided with 3 rd trimester pregnancy, osteoarthritis or degenerative hip pathologies
- Treatment Goals
 Edema in the foot and leg are better addressed after compressions
 Positioning
 Prone or side-lying
 Additional pillow under ankles if edema is present
 Treated in neutral position NOT external rotation
 Supine in the presence of lordosis
 Address iliopsoas, rectus femoris and QL
 Joint mobilizations on lower back
 Pes Planus
 Address feet
 Hydrotherapy
 Deep moist heat over the buttock and lumbar region
 If edema is present, cool towel
 Contrast as post-treatment to improve circulation and flush metabolites
 Techniques
 Skin rolling
 Effleurage
 Petrissage: C-scooping and fingertip kneading along iliac crest and sacrum
 Muscle stripping
 Ischemic Compressions
 *** Sacrotuberous ligament is treated with muscle stripping from ischial tuberosity superiorly toward the sacrum
 PROM
 Stretching
 supine
 PNF through agonist contraction
 Decrease pain  Decrease sympathetic nervous system firing
 Treat any compensatory structures
 Decrease compression on the sciatic nerve
 Reduce TP
 Decrease inflammation if present
 Promote tissue health and circulation
- Self-Care Goals
 Stretch tight, short muscles (translation: piriformis)
 Hamstrings
 Calves
 Tennis ball on gluteal and piriformis
 Eccentric lengthening contraction of piriformis
 Educate client
 Rocking chair
 Change positions
 Keep feet and knees to midline
 Sleeping position, pillow between legs to avoid adduction
 Frequent breaks during activity with stretching
 Refer  chiropractor and orthotics if pes planus and Hyperpronation are present
Handout – Piriformis Syndrome
- Anatomy
 Piriformis muscle lies deep to the gluteal muscles
 Originates from the sacral spine and attaches to the greater trochanter of the femur
 The sciatic nerve usually passes underneath the piriformis muscle, but in approximately 15% it travels through the muscle
 The piriformis muscle assists in abducting and laterally rotating the thigh
 Enables us to walk, shift our weight from one foot to another and maintain balance
- Piriformis Syndrome is an uncommon neuromuscular disorder that is caused when the piriformis muscle compresses the sciatic nerve
- Causes/Mechanism of Injury
 Patients with nerve passing through the muscle are particularly predispose to this condition
 Trauma to the buttock
 Overuse
 Leg length discrepancy
 Fibrosis after an injection in the buttock
 Abnormal gait
 SI dysfunction
 Sitting with wallet in pocket
 Poor lower extremity bio mechanics
- Symptoms
 Piriformis muscle is irritates the sciatic nerve causing pain in the buttock and referring pain along the course of the sciatic nerve
 This referred pain is called “pseudo-sciatic” often does down the back of the thigh and/or into the lower back
 General complaint of pain deep in the buttocks made worse by sitting, climbing stairs or performing squats
 Other common symptoms include: gluteal atrophy and spontaneous fasciculation’s of the muscles of the calf, buttock, and hamstrings
- Treatment
 Include piriformis stretch, which aims to correct the underlying pathology by relaxing a tight piriformis, and related muscle stretching to relieve nerve compression
 Using moist heat or ultrasound prior to stretching is most often suggested
 Stretches can be performed in sitting, standing and supine position, and they involve hip and knee flexion, hip adduction, and internal rotation of the thigh
 May cause a reoccurrence of symptoms
 Various therapeutic injects may be considered, including: local anesthetic, corticosteroids, or Botox
- Common Massage Therapy Treatments
 Stretching hip musculature
 Strengthening hip musculature
 Ice/heat to decrease symptoms
 Heat to increase extensibility
 Mobilization of sacroiliac region and hip
 PNF using contract-relax technique
 Myofascial release technique
Other Connective Tissue Disorders

Bunions
Bunions
Definition Etiology Treatment
- AKA: Hallux valgus (“laterally deviated great toe”) - Factors that put pressure at the metatarsal-phalangeal joint: - NSAIDs
- 1st phalanx of the great toe is distorted  Pes cavus or pes planus - Injected cortisol
- At the little toe: “tailor’s bunion”  Muscle imbalances in foot, lower leg Massage Therapy Implications
Demographics  Shape of the bones Risks: Acute inflammation locally contraindicates intrusive massage
- Women > men, 10:1  Footwear that squeezes toes, forces weight forward Benefits: Work around the painful area—within tolerance—may
- Genetic predisposition - When the joint is distorted: improve range of motion and function for the joint, but it won’t
- Adults who wore too-small shoes as children  Friction bursitis reverse bony deformation
Signs and Symptoms  Bone spurs Options: Focus on intrinsic foot muscles, look for other postural
- Large lump on medial side of great toe  Osteoarthritis and gait compensations
- May be palpably hot and swollen
A bunion is a protrusion at the metatarsophalangeal joint of the Bunions are recognizable by the large bump on the medial aspect Risks: Bunions locally contraindicate deep specific massage, which
great toe that occurs when the toe is laterally deviated. of the foot. When they are inflamed, they are red, hot, and painful. may exacerbate inflammation and pain.
Benefits: Lymphatic work to reduce local inflammation may help
with some bunion pain, and work elsewhere on the foot and with
other gait compensation patterns may be helpful for a client with
this painful condition.
Bursitis
Bursitis
Definition Signs and Symptoms Massage Therapy Implications
- Inflammation of a bursa - Pain on passive and active movement of the joint Risks: Acute bursitis can be exacerbated by invasive touch; avoid
 Internal cells proliferate, generate excess fluid, cause - Extremely limited range of motion acute infections, of course.
pain and limitation - Infection (rare) may show palpable heat, redness Benefits: Massage therapy that doesn’t make symptoms worse
- Hundreds of bursae throughout the body Treatment may help with muscle tension and range of motion. Someone with
- Most common site of bursitis: subacromial bursa - Usually self-limiting a history of bursitis and no symptoms can enjoy the benefits of
Demographics - Rest massage.
- Most common among active people - Oral anti-inflammatories Options: Address the muscles that cross the affected joint to help
- Location depends on activity - Hot, cold packs restore range of motion and to decompress the area.
Etiology - Aspiration
- Bursae ease the movement of tendons over corners, cushions - Steroid injection
where bones might collide - Surgery if necessary
- Repetitive stress is irritating; causes them to inflame Medications
 Very painful - NSAIDs
 Nearby muscles splint the area - Injected cortisone
 Structural changes to bursae may become permanent - Antibiotics for septic bursitis
- Often see with other joint injuries
- Most common: shoulder, knee, ischium
- May involve local infection (septic bursitis)
A bursa is a fluid-filled sac that acts as a protective cushion, eases Acute bursitis is painful and is aggravated by both passive and Risks: Acute bursitis locally contraindicates any massage that is
the movement of tendons and ligaments moving over bones, and active motion. Muscles surrounding the affected joint often deep or specific. Bursitis due to infection contraindicated massage
cushions points of contact between bones. Bursitis is the severely limit range of motion. It may be hot or edematous if the until the infection has been treated and eradicated.
inflammation of a bursa. bursa is superficial. Benefits: Lymphatic work to reduce local inflammation may help
with some bursa pain, but doesn’t address the root of the
problem. Massage elsewhere on the body during an acute phase
and directly to the muscles around the affected joint (within pain
limits) in a subacute phase is appropriate.
Shin Splints
Shin Splints
Definition Types of Shin Splints Treatment
- A group of lower leg injuries Medial Tibial Stress Syndrome - Reduce activity
- Sometimes connected to compartment syndrome - Most common presentation - Alternate hot and cold packs
Demographics - Injury at the medial side of the tibia: soleus and tibialis anterior - Change footwear
- People who are physically active are most vulnerable: - Most painful at the distal 1/3 of medial tibia - Analyze movement, training patterns
 Military in training camp Tibialis Anterior, Tibialis Posterior Injury - If symptoms don’t subside, pursue for
 Runners - Pain runs most of the length of the lateral tibia (tibialis  Stress fractures
 Gymnasts anterior) or deep in the calf (tibialis posterior)  Chronic compartment syndrome
 Dancers Periostitis Medications
Etiology - Inflammation of the periosteum - NSAIDs
- Several factors make the lower legs susceptible to injury: - Could be anywhere the muscles fray, pull away from the bone Massage Therapy Implications
 Long muscular attachments to periosteum of tibia, Stress Fractures Risks: Palpably hot, inflamed lower legs may require medical
fibula, crural fascia, interosseus membrane - Pain can be mild-severe attention. Shin splints that don’t improve also require medical
o Irritation to muscles can reverberate to these - Made worse with activity attention. Otherwise, massage therapy is safe and appropriate.
other structures - Not visibly inflamed, but palpation is painful Benefits: Mild irritation may respond well to massage therapy
 Shock absorption at the feet - (Visible inflammation may indicate acute compartment Options: Pin-and-stretch techniques can work with shin muscles
o If compromised, the tibia-fibula are affected syndrome, a medical emergency) that are hard to mobilize
 Exercise: sudden changed in routines, all uphill or all Research: Ice massage was investigated for medial tibial stress
downhill, worn out shoes syndrome; it did not stand out as better than other interventions
The term “shin splints” refers to a collection of lower leg injuries, Pain along the tibia may be superficial or deep, mild or severe. The Risks: Some shin splint situations may contraindicate massage until
including muscle injuries, periostitis, hairline fractures, and other pattern of pain differs with the specific structures that are injured. more information is gathered, or the acute stage has passed.
problems. They are usually brought about by overuse and/or Compartment syndromes can be a serious complication, and bone
misalignment at the ankle. fractures need different treatment options and healing times than
other injuries.
Benefits: Massage therapy can be helpful to treat uncomplicated
muscle injures around the tibia, and it can also be a useful strategy
to augment training and reduce the risk of injury to the lower leg
muscular and fascial structures.
Tendinopathies
Tendinopathies
Definition Types of Tendinopathies Treatment
- Umbrella term for injury, damage to tendon, tenosynovial Tendinitis - Rest, ice, stretching and exercise
sheaths - New injury - Ultrasound, extracorporeal shock wave therapy
 Can be acute - Classic signs of inflammation - Eccentric contractions seem to be most effective
 Usually related to chronic degeneration of connective - Short-lived - Splint or brace if necessary
tissue Tendinosis Medications
Demographics - Long-term degeneration of tendon - NSAIDs for pain (not inflammation)
- Very common, all populations - Collagen fibers are disorganized - Steroids are traditional, but now are used sparingly
- With age, tendons lose some elasticity, become more  Mostly type 3, thinner and weaker than type 1 Massage Therapy Implications
vulnerable to damage and slow healing - Happens mostly at… Risk: Lymphatic work is useful during acute phase, otherwise avoid
- Associated with some disorders  Rotator cuff the area
 Rheumatoid arthritis  Biceps tendon Benefits: For chronically injured structures massage and exercise
 Lupus  Medial and lateral epicondyles of the humerus can be helpful
 Chronic renal failure  At the patella Options: With-fiber, cross-fiber friction at damaged area may be
 Quinolone-type antibiotics  Distal attachment of the iliotibial band helpful, especially in the client also carefully exercises the
 History of steroid injections  Achilles tendon structures
Etiology Tenosynovitis Research: Massage therapy is shown to be helpful, and a useful
- Changes in injured tendons… - Irritation at tenosynovial sheath option before pursuing more invasive treatment options
 Acute: secretion of pro-inflammatory chemicals, etc. – - Usually at wrist or hand
“tendinitis”  Trigger finger: any finger but the thumb; flexor tendon
 Most tendinopathies do not involve acute tendinitis can become struck so it is difficult to extend the finger
 Collage degenerates faster than it is replaced  DeQuervain tenosynovitis: at the abductor and
 Tendon loses weight-bearing capacity extensor pollicis tendons of the thumb
 This is tendinosis  May be acutely inflamed
- Healthy tendons:  May be related to infection
 Limited stretch and rebound
 Hard, white, shiny
- Degenerated tendons:
 Tendons are dull, gray, shaggy
 Limited weight-bearing strength
 Overuse without recovery
 Poor flexibility
 History of cortisol injections
 Training errors
 Fall or other injury
Whiplash
Whiplash
Definition Signs and Symptoms/Complications Medications
- AKA cervical acceleration-deceleration - Ligament sprains - NSAIDs, narcotics
- Mixture of accident-related injuries, including: - Damaged facet joints - Antidepressants for pain, sleep, sedation
 Sprains - Subluxated cervical vertebrae - Muscle relaxants
 Strains - Damaged discs - Injected or oral steroids
 Joint disruptions - Muscle spasm, trigger points - Injected analgesics
 Fractures - CNS damage: traumatic brain injury, spinal cord Injected Botox
 Disc disease contusion Massage Therapy Implications
 Traumatic brain injuries - TMJ disorders Risks: It is possible to disrupt tissues before they have fully healed,
 Others - Headaches even many weeks after an accident. Be sure injuries to bones, disc,
Etiology Treatment nerve tissue, other organs have been attended to. Don’t work for
- Factors that determine whiplash injuries from motor vehicle accidents: - Neck collars (as short a time as possible) big changes; that may create a major setback.
 Direction of impact - Heat, ice Benefits: Massage can address muscle holding that outlasts its
 Speed of vehicles - Electric stimulation usefulness, but it must be in incremental steps. Massage can also
 Relative weight of vehicles - Physical therapy, massage therapy address scar tissue, pain, loss of range of motion and other
 Seat belt use - Traction problems, especially in combination with spinal manipulation
 Position of the head - Exercise and strengthening Research: Long-term whiplash symptoms appear to be closely
 Awareness of impending collision - Pain relievers related to muscle injury and anxiety/depression; massage therapy
- Other whiplash injures from: - Anti-inflammatories has been shown to be a useful intervention for all of these
 Sports injuries - Muscle relaxants
 falls
- Structures at risk:
 SCM, scalenes, splenius cervicis muscles
 Supraspinous and intertransverse spinal ligaments
 Anterior and posterior longitudinal ligaments
 Facet joint capsules, TMJ
 Intervertebral discs
 Vertebrae
 Soft tissues of neck and throat: esophagus, trachea, larynx
- Can lead to chronic pain, central sensitization
Whiplash is a collective term referring to a collection of soft tissue injuries Symptoms of whiplash vary according to the nature of the Risks: Acute injuries, along with those that have not been fully
that may occur with cervical acceleration followed by deceleration. These injuries. Post-trauma pain at the neck and referring into the diagnosed, contraindicate any but the gentlest bodywork. The risk
injuries include sprained ligaments, strained muscles, damaged joint shoulders and arms, along with chronic headaches, are the of exacerbating inflammation or of disrupting unstable bones or
capsules, and temporomandibular joint problems. Although whiplash most frequent indicators. joints are important to respect.
technically refers to soft tissue injury, damage to other structures, Benefits: Post-acute and mature whiplash injuries can benefit from
including vertebrae disc, and nerve tissue, frequently occurs at the same massage that focuses on restoring healthy muscle tone and
time. movement patterns, along with improving the quality of any
connective tissue scarring that may have occurred.
- Whiplash is an acceleration-deceleration injury to the head and neck

- Unrelated clinical symptoms: headaches, dizziness and temporomandibular joint disorder
- Motor vehicle accident can come from rear, side or front impact
- Rear impact results in more long-term symptoms
- AKA – cervical sprain, cervical herniated disc and cervical facet joints sprain
- CAD (cervical acceleration/deceleration)
- WAD (whiplash-associated disorders)
- Contributing factors: active trigger points in SCM (from looking over shoulder during driving) resulting in dizziness
- Motor Vehicle Accidents:
 Rear Impact
 Long-term symptoms
 Acceleration rate of the victim’s head is greater than the vehicle
 Result in mild SCM strains to severe longus coli muscle tears
 Accompanied by retropharyngeal hematoma, esophageal hemorrhages and cervical sympathetic nervous system damage
 LESS COMMON anterior longitudinal ligament
 Avulsion of intervertebral disc – x-ray
 4 distinct phases
1. Phase 1 – 60 milliseconds – vehicle is struck from behind cause the body to go back
2. Phase 2 – 120 milliseconds – the vehicle and torso reach peak forward
 Anterior neck muscles and ligaments are over stretched and TMJ may be injured
3. Phase 3 – 160 milliseconds – head and neck are at their peak forward position while vehicle and torso slow down
4. Phase 4 – 280 milliseconds – head and torso are now at full deceleration
 Other factors
 Head positions
 If head is turned greater stress is placed on the ipsilateral facet joints and compressing cervical nerve roots
 Splenius cervicis also injured in this position
 Seatbelts
 Especially injured in low-speed collisions
 Injuries viscera and bruising to the chest under the shoulder harness
 Headrest Position:
 If too low the neck causes further extension
 Seat back, hyperkyphotic posture will increase injury
 Stature
 Short 40% lower risk of neck injury than taller
 Shorter greater injury from shoulder harness
 Airbags
 Provide little protection in rear-impact collisions
 Front Impact
 Reverse of the above ^^^
 But may be able to brace for impact
 Side Impact
 Lateral flexion of the neck and torso, lumbar possibly
- Quebec Task Force Classification (QTF)
 Grade 0
 There is no complain about the neck; no physical (musculoskeletal or neurological) signs
 Grade 1
 There is neck complaint of pain, stiffness or tenderness only; there are no physical (musculoskeletal or neurological) signs; microscopic lesions are not serious enough to cause muscle spasm
 Resolves in less than 3 weeks
 Grade 2
 There is neck complaint of pain, stiffness or tenderness; there are musculoskeletal signs of decreased range of motion and point tenderness; injury to muscles, tendons, ligaments and joint capsule is serious enough to cause muscle
 Resolves 4-6 weeks
 Grade 3
 There is neck complaint of pain, stiffness or tenderness; there are neurological signs including decreased or absent deep tendon reflexes, weakness and sensory deficit; injury to the neurological system is due to mechanical injury or secondary to
inflammation or bleeding
 6+ weeks
 Grade 4
 There is neck complaint and fracture or dislocation
 6+ weeks
 Grade 1  6 week treatment; Grade 2 and 3  12 week treatment
 Other symptoms
 Symptoms and disorders that can appear in all grades include deafness, dizziness, dysphagia, headache, memory loss, temporomandibular joint pain and tinnitus
 Time Axis
 People are classified within each grade in terms of days following the injury: less than 4 days; 4 days to 21 days; 22 to 45 days; 46 to 180 days; and more than six month’s duration
- Special Tests
 Vertebral artery test
 Swallowing test
 Scalene cramp test
 TOS – Adson’s, Travell’s variation, wright’s hyperabduction, costoclavicular syndrome and Eden’s test
 Dermatome and myotome
 Strength and length tests
 Upper limb tension test
 Spurling’s, cervical compression and cervical distraction tests
- Contraindications
 In the acute stage, Grade 2 or higher whiplash other than pain-free active free range of motion and neurological testing (DTR and sensory and motor testing) is contraindicated to prevent further tissue damage
 In subacute and chronic stages, refer the client for medical attention if the vertebral artery test is positive
 Avoid removing the protective muscle splint of acute whiplash
 Do not passively stretch a muscle that is in spasm
 Avoid extreme stretches of the cervical muscles, especially to sternocleidomastoid and the larger posterior cervical muscles in the acute to subacute stages
 Avoid mobilizing hypermobile vertebrae, usually at C4-6
 Joint play for the spine should not be painful
 Avoid overly aggressive techniques in the subacute and chronic stages; these may provoke a flare-up of acute symptoms
 Do not compress over the carotid artery or carotid sinuses when treating the anterior neck muscles
 Do not use massage techniques bilaterally on both SCM at the same time as the carotid arteries may be compressed
 Client may feel choked
 Frictions are contraindicated if the client is taking anti-inflammatories or blood thinners
- Treatment Goals
 Treat any compensating structures—maintain local circulation
 Reduce inflammation—reduce edema
 Reduce but do not remove protective muscle spasm
 Do not disturb any hematoma present
 Prevent adhesion formation
 Reduce spasm
 Reduce trigger points without disturbing the injury site—SCM, infra- and suprahyoid muscles
 Treat specific injury site
 Maintain and increase range of motion
 Treat compensating structures
 Reduce tone in the neck and shoulders—infra- and suprahyoid muscles, anterior and posterior thoracic, neck and shoulder muscles
 Increase range of
Polymyalgia Rheumatica
Polymyaglia Rheumatica
- “multiple muscle and joint pain” - Deep, aching pain of the neck, shoulders and hips - Goes away by itself in 2-3 years
- Involves aching, stiff sore muscles and joints - Short onset develops over a matter of days - Long-term low dose steroids
- Persists for months or years then spontaneously disappears - Worst after inactivity - Vitamin D and calcium supplements to deal with bone thinning
- Idiopathic condition affects most white women 50-80 years old - Morning stiffness persists for hours or days - Stay active
Etiology - May be one side and becomes bilateral Medications
- Unknown cause - Proximal joints first site of pain, upper arms and thighs - Corticosteroids to control inflammation
- Combination of genetic predisposition, exposure to an - Limited ROM - High-dose steroids for giant cell arteritis
environmental trigger, and abnormal monocyte activation - Some have low-grade level, malaise, fatigue and weight loss Massage Therapy Implications
along with presence of several proinflammatory cytokines Other Types of Polymyalgia Rheumatica: Giant Cell arteritis (GCA) Risks: Massage may exacerbate pain for a client rather than relieve
- Signs of recent virus infection - Somehow linked, 20% PMR develop GCA, and about 60%of GCA it. Corticosteroids may have cautions for massage. Clients with
- Typically affects the neck, shoulders, hip, and proximal limbs develop PMR symptoms of giant cell arteritis (like headache) must see a health
- Joint muscles are painful cause of fasciae, bursae and synovial - Also called temporal arteritis or cranial arteritis care provider right away.
capsules being mildly inflamed - Blood vessels become inflamed in head and face Benefits: Gentle massage that is soothing and nonchallenging may
- Joint inflammation leads to no permanent damage - Risk of vision loss or stroke help decrease pain and stiffness in clients with PMR.
- Symptoms: jaw and scalp pain, headache, and visual
impairment
- Immediate medical attention
Torticollis
- Torticollis is an abnormal positioning of the head and neck relative to the body
- Muscles affected: SCM, upper trapezius, levator scapula and scalenes, splenius cervicis, splenius capitis, multifid, rotatores and suboccipitals
- Acute Acquired Torticollis
 Acute acquired torticollis is a painful unilateral shortening or spasm of neck muscles resulting in an abnormal head position
 Causes:
 Activation of latent trigger points  SCM, scalenes, levator, splenius capitis and suboccipitals
 Subluxation of C1 on C2  whiplash or sudden turning of the neck (may be spasm), infection, emotional stress or cold
 Muscle guarding, intrinsic muscle spasm
 Facet joint irritation  trauma, jarring of the spine or abrupt movement
 Infection  tonsils, inflammation of the throat or cervical lymphatic nodes
 Disc-related pain
 Symptoms
 Children and adults, usually under 30
 Sudden onset “just wake up with it”
 Torticollis position  neck extension or flexion
 Affected muscles are shortened and in spasm
 Apprehension, pain facial expression
 Breathing is apical and rapid
 SCM  tinnitus, nausea or tearing of the eye, referred pain
 Facet joint irritation  movement on neck or scapula
 Cervical degenerative disc disease
 Sleeping in awkward position
 Pain may go into the arm
 May be on: analgesics and muscle relaxants
 May resolve on it’s own
- Congenital Torticollis
 Congenital torticollis is a contracture of one sternocleidomastoid muscle resulting an abnormal head position
 Infancy  adulthood
 Causes:
 Predisposing factors may be trauma, tissue ischemia, cranial bone torsion or cranial membrane dysfunction
 Symptoms
 Days or weeks after birth
 Torticollis position
 Contracture, thickening and shortening of SCM, scalenes and fascia (may not have palpable muscle mass)
 Unable to move neck
 Not described as painful
 Scoliosis and hemihypoplasia are likely present (or seen over time)
 Compression on cranial nerves and vasculature, TMJ dysfunction, degeneration of cervical disc and osteoarthritis
- Spasmodic Torticollis
 Spasmodic torticollis is a localized dystonia resulting in an involuntary spasm of cervical muscles and an abnormal head positions
 Worsens under stress
 Causes:
 Idiopathic (4/5 cases)  linked to depression, severe stress, social or personal upheavals and occupational positions of the head
 Central nervous system lesions  encephalitis and basal ganglion disease
 Malformation  atlanto-occipital articulation
 Postural dysfunction  such as scoliosis
 Trauma  head and neck
 Iatrogenic  Parkinsons
- Contraindications
 For any torticollis, avoid full stretches to the SCM muscle if the vertebral artery test is positive or if the client experiences dizziness with the stretch
 Avoid working over the pulse of the carotid triangle immediately anterior to the SCM muscle and inferior to the angle of the mandible
 For acute acquired torticollis, do not passively stretch the spasmodic muscles
 For congenital torticollis, if working with infants, use reduced pressure when treating the contractures
 For spasmodic torticollis, painful techniques, joint play and local direct massage are contraindicated as they make the spasm
- Special Tests
 Postural assessment
 Palpation
 Cervical Strength Tests
 Compression and cervical distraction tests
 Vertebral artery test
 Spurling’s Test
- Treatment Goals
 Stress reduction
 Trigger point
 Postural awareness
 Increase extensibility
 Reduce tone/tension
 Pain reduction
 See whiplash, tension headache, degenerative disc disease, osteoarthritis, Parkinsons and temporomandibular joint dysfunction
Iliotibial Band Contracture & Iliotibial Band Friction Syndrome

- Iliotibial band contracture is a contracture or thickening of the iliotibial band
- Iliotibial band friction syndrome is inflammation and pain where the iliotibial band crosses the lateral femoral condyle
- Can be uni or bi laterally
- IT band is fascia connecting to the TFL, gluteus maximum to the proximal tibia (gerdy’s tubercle)
- Action is knee support and extension
- When the fascia is contracture knee and hip as restricted
 Ankle and SI joint may compensate
 Greater trochanteric bursa may become inflamed
- TPs in the TFL and gluteus maximum may contribute IT band tightness
- Causes of IT band contracture:
 Activities or occupations that place the knee and hip in flexion (shorten)
 ex. cycling, horseback riding or prolonged sitting
 TFL ex. running on sloped or banked ground
 Those with pronated feet or inadequate footwear
 Postural imbalance
 Anterior pelvic tilt or hyperlordosis from weak gluteus medius or short rectus femoris or habitual leaning on one leg
 Prolonged wheelchair use or bedrest
- Causes of iliotibial band friction syndrome:
 Prolonged, repetitive activities where the knee and hip are flexed, such as running or cycling
- CONTRIBUTING Factors: poor TFL stretches and pelvic tilt
- Symptoms
 Pain is gradual and worse on activity on lateral thigh and knee
 Lumbar pain
 Thickening, adhesions and possible fibrotic nodules can be found along the affected iliotibial band
 Inflammation near the lateral femoral condyle or greater trochanteric bursa
 Hypertonicity and TPs in the TFL, hip flexors and rectus femoris
 Reduced circulation and shortening of muscles involved
 Anterior pelvic tilt
 Hypermobility of SI joint
 Valgus or hyperextension of the affected knee
- Assessments
 Observation
 Well-defined IT band creates an indentation of the lateral aspect of the thigh
 Anteriorly low lateral pelvic tilt
 Knee presents with valgus
 Pes planus on affected side
 Anterior pelvic tilt
 Hyperlordosis
 Short rectus femoris or hip flexors
 IT band friction syndrome:
 Redness
 Local edema near femoral condyle
 Palpation
 Tenderness along IT band, especially distal third or greater trochanter (bursa)
 It is thickened, adhesions
 Increased tone
 TPs in TFL and gluteus maximus on affected side, opposite iliopsoas, adductors and QL
 IT band friction syndrome:
 Tenderness, heat and swelling of the lateral femoral condyle
 Special Tests
 ROM
 Knee, hip and SI joint
 AROM
 Reduced extension and adduction of hip
 Reduce extension of knee
 PROM
 Knee, hip and SI painful extension
 Lateral aspect of knee for IT band friction syndrome
 ISO
 Stronger TFL, hip flexors and gluteus maximum
 Weaker gluteus medius
 Special Tests
 Length Tests of rectus femoris and iliopsoas
 Thomas and Ely’s Test
 Obers Test
 Noble’s Compression Test
- Treatment Goals
 Hydrotherapy  deep moist heart, dipped wax; cool compress or contrast after fascial work; cold if inflammation is present
 Reduce the contracture fascia
 Reduce TPs
 Reduce inflammation
 Increase local circulation to remove metabolic waste
 Treat compensatory structures
- Frequency
 Depends on length of time the contracture has existed and any perpetuating factors
 Ex. hyperlordosis
Nervous System Conditions

Chronic Degenerative Disorders
Alzheimer disease
Alzheimer disease
- Progressive degenerative disorder causing… - Can occur quickly or slowly, often over many years
 Memory loss - Key changes:
 Personality changes  Loss of recent memory
 Finally, death  Poor judgement
Demographics  Disorientation in time and space
- Diagnosed in 5 million in US  Problems with word-finding
 500,000 deaths/year  Depression, anxiety, paranoia, aggression
 Expected to triple by 2050  Difficulty with complex and simple tasks, self-care
- $214 billion per year  Eventually… walking, communicating, organ function are lost
- Incidence is tied to age Treatment
- Women > men (possibly because they live longer) - No single treatment
- A version affects younger people - Strategies to slow the process, help with other problems (i.e., anxiety, depression)
 200,000 patients under age 65 Medications
Etiology - Cholinesterase inhibitors
- First lesions described in 1906: - Antidepressants
 Plaques and tangles - Anti-anxiety medication
- Plaques: - NSAIDs
 Deposits of beta amyloid (sticky, trigger inflammatory response that kills cells) Massage Therapy Implications
- Tangles: Risks: Be aware that in older clients other diseases may also be present. Verbal communication may be
 Related to generation of tau in neuron cells membranes; long fibers collapse and lose their difficult, and they are vulnerable to confusion, disorientation: watch for non-verbal signals about
connections comfort.
- Consequence: Benefits: Massage Therapy may improve quality of life and reduce some negative aspects of this
 Low levels of important neurotransmitters, so functioning cells are also affected condition.
 Hippocampus (memory center) shrinks Research: Massage therapy seems to help with orientation, combativeness, and restlessness for
- Contributing factors: people with Alzheimer disease
 Genetics
 Chronic inflammation
 History of head injuries
 Exposure to toxins
 High cholesterol
 Low estrogen
 Etc…
Amyotrophic Lateral Sclerosis
Amyotrophic Lateral Sclerosis

Definition Types of Amyotrophic Lateral Sclerosis Treatment
- AKA ALS, AKA Lou Gehrig disease (US); motor neuron disease Sporadic Amyotrophic Lateral Sclerosis - Treatment addresses fatigue, spasms, secondary infection
(Great Britain) - Most common, 90-95% of all cases in US - Some drugs limit glutamate
- Progressive, fatal condition - Random distribution across the population - Other drugs for other symptoms
 Destroys motor neurons in CNS and PNS Familial Amyotrophic Lateral Sclerosis - Moderate exercise, PT, occupational therapy
 They are replaced by fibrous astrocytes (scar-like) - Clear genetic link - Heat, whirlpools for muscle spasms
- Amyotrophic = muscle atrophy - 5-15% of cases in US - Speech therapy
- Lateral sclerosis = scarring on sides of the spinal cord - Often has earlier onset than sporadic variety - Assistive devices
Etiology Mariana Islands-Type Amyotrophic Lateral Sclerosis - Later: gastrostomy, respirator
- Causes are unknown - Endemic to Western Pacific islands, especially Guam ???? Medications?
- Motor neurons in CNS and PNS die Signs and Symptoms Massage Therapy Implications
 Microglia should be protective, but they add to - For 75%: earliest symptoms in hands and feet, then arms and Risks: Be careful not to trigger painful spasms. Patients become
damage legs frail, and require adaptations as their bodies weaken
 Inflammation throughout CNS - Bilateral but one side may be worse than the other Benefits: Massage can fit with heat, exercise, PT; best as part of an
 Damage in frontal lobe (decision-making, execution) - Fatigue, Cramping, stiffness, weakness integrated team. Massage therapy may address spasms, stress,
- Surviving motor grow new axon branches to expand the size of - Moves proximally toward trunk other aspects of living with this disease
each motor unit  Finally affects muscles for breathing Options: Focus on reducing pain, and improving breathing
 Ultimately, they fail, and muscle cells atrophy - For 25%: earliest symptoms with Research: Massage therapy is popular among ALS patients, so we
- Contributing factors  Speech, swallowing, motor control of the tongue need to know how to serve them. Massage therapy has been seen
 Genetic predisposition  “Bulbar” ALS to reduce constipation and help with spasticity with other
 Oxidative injury to CNS - Upper motor neuron damage: progressive spasticity, conditions
 Mitochondrial dysfunction exaggerate reflexes
 Premature cell death - Lower motor neuron damage: weakness, atrophy, cramps,
 Glial cell pathology fasciculations
 Too much glutamate; excitotoxicity - Both are affected with ALS
- ALS affects only motor neurons—sensation is intact
Amyotrophic lateral sclerosis (ALS) or Lou Gehrig disease is a Symptoms of ALD include weakness, fatigue, and muscle spasms. It Risks: Some patients experience painful spasms with certain
progressive disease characterized by degeneration of upper and appears most frequently in patients between 40-70 years old. stimuli, and any massage must be designed to minimize this
lower motor neurons and consequent atrophy of voluntary response. Patients with advanced ALS become frail and vulnerable
muscles. to secondary infection. They may use devices to help with eating
and breathing. All of these require adjustments in body work
Benefits: Because patients with ALS have full sensation, massage
that respects frailty, medical equipment and other risks can be safe
and welcome. Massage may help to maintain muscle function and
mobility, and to delay the atrophy that is part of this disease.
Huntington Disease
Huntington disease
- Progressive, terminal disease of the CNS - 3 main categories:
- Autosomal dominant genetic mutation 1. Motor function
 Only 1 gene needed  Clumsiness, dystonia, twitching, tics at face
 Not gender-based  Twitching, tics affect whole body
Demographics  Possible rigidity, tremors, seizures
- Estimated 15,000-30,000 in US have Huntington disease 2. Emotional stability
- Estimated 150,000-250,000 carry a gene  Mood swings, apathy, hostility, depression
- Onset is usually between age 35-44 3. Cognition
- Men = women  Cognitive decline
 Men usually progress more quickly  Loss of attention, learning, judgement, decision-making
Etiology Treatment
- AKA: dancing mania, hereditary chorea; Huntington chorea - Genetic mutation is not treatable
- Genetic mutation changes activity in basal ganglia and cerebral cortex - Drugs for symptoms
 Irreversible, progressive cell death and loss of brain function - Counseling
 Degeneration causes astrocytes to multiply, interfere with neuron - Speech therapy, occupational therapy, physical therapy
 Suppresses secretion of important neurotransmitters Medications
- Huntington disease is terminal - Tetrabenazine
 Death from pneumonia, injury, suicide - Antipsychotics
 Life expectancy 10-20 years after symptoms develop - Tranquilizers
- Antidepressants
Massage Therapy Implications
Risks: Emotional volatility and cognitive decline may make massage problematic; it is important to confirm that touch is
welcomed. Patients may become frail with progression; appropriate adaptations are needed.
Benefits: Massage may work with a fitness program to maintain function, decreases stress, soothe anxiety.
Options: Use imagination and flexibility to keep the client safe and satisfied.
Peripheral Neuropathy
Peripheral neuropathy
Definition Treatment
- Not a disease - Depends on cause
 Usually a symptom or complication  Topical ointments with lidocaine, capsaicin
- Peripheral nerves are damaged through  TENS units
 Lack of circulation  Biofeedback
 Chemical imbalance  Acupuncture
 Trauma  Relaxation techniques
 Other factors Medications
Etiology - Analgesics
- Mononeuropathy = 1 nerve - Anti-inflammatories
- Polyneuropathy = multiple nerves - Immunoglobulins
- Usually a consequence of… - Antiseizure drugs
 Injury, compression (i.e., carpal tunnel syndrome…) - Tricyclic antidepressants
 Infection (i.e., herpes simplex…) Massage Therapy Implications
 Systemic disease (i.e., diabetes mellitus…) Risks: Undiagnosed pain or tingling needs to be seen by a primary care provider before massage.
 Toxic exposure (i.e., chronic alcoholism…) Numbness can be a caution when it interferes with accurate client feedback. Any touch may be
Signs and Symptoms irritating; be willing to delay if symptoms are exacerbated.
- Often has subtle, slow onset Benefits: Soothing touch may provide relief from stress and pain, but it must be determined on a case-
- Symptoms can reflect damage to… by-case basis
 Sensory nerves Research: Massage therapy has been shown to be helpful for several types of peripheral neuropathy,
 Pain, tingling, hyperalgesia, allodynia, numbness including chemotherapy-induced: an important finding that might allow people to tolerate treatment
 Motor nerves better.
 Twitching, cramping, atrophy
 Autonomic nerves
 Problems with digestion, heart rate, respiratory rate, blood pressure, bladder/bowel
control
Movement Disorders
Dystonia
Dystonia
Definition Types of Dystonia
- Common condition with repetitive, involuntary contractions of skeletal muscles Focal Dystonia
Demographics Cervical dystonia
- Among all ages and races  AKA spasmodic torticollis; most common
- Women > men  Involuntary contractions of neck rotators
Etiology Vocal dysphonia
- May be linked to basal ganglia, inability to process some neurotransmitters  Shaky, hoarse, whispery voice
- Results: bursts of electrical activity in affected muscles, causing short or prolonged contractions  AKA laryngeal dystonia
- Causes include… Oromandibular dystonia
 Genetic predisposition  Face and low jaw muscles
 Underlying neurological disorders  Problems with eating and swallowing
 Reactions to medications Blepharospasm
Signs and Symptoms  Repetitive, forceful blinking
- Depends on type  Functional blindness
- Involuntary contraction Multifocal Dystonia
 Short or sustained - Affects disconnected parts of the body
 Multiplane movement, twisting  i.e., left leg, face
- Exacerbated by stress, fatigue Segmental Dystonia
- May be task-related - Affected contiguous areas
 “Geste antagoniste” to reduce contractions Meige syndrome
- Usually not painful, may cause headache, muscle irritation  Blepharospasm + oromandibular dystonia
Treatment Upper limb dystonia
- Physical therapy, gentle stretching  “writer’s cramp” – dominant hand develops cramps while writing
- Oral, infected medication to affect neurotransmitter secretion  Seen in many professions
- Botulinum to block acetylcholine receptors Lower limb dystonia
- Deep brain stimulation  Rare, mostly in children
Medications Hemidystonia
- Levadopa - Affects the left or right side of the body
- Benzodiazepines - Occasional result of stroke
- Baclofen Generalized dystonia
- Anticholinergic medications to block acetylcholine Paroxysmal dystonia
- Botox injections  Symptoms affect many areas; can resemble a seizure
Massage Therapy Implications  Attacks last minutes-hours
Risks: Be aware of medications; some interfere with pain or stretching signals. Torsion dystonia
Benefits: Because dystonia is exacerbated by stress and fatigue, massage therapy may help with this.  Trunk and limb
Research: Very small studies support massage for hemifacial spasm and infant muscular torticollis.  Writhing, twisting spasms
Tardive dystonia
 Complication of longtime use of antipsychotic drugs
 Usually subsides if drug use stops
Parkinson Disease
Parkinson disease
Definition Primary Signs and Symptoms Treatment
- First known as “shaking palsy” - Resting tremor: - Complex: balancing risks and benefits of medications with the
- Movement disorder with progressive degeneration of nerve  Hand, foot, head, neck needs of the patient
tissue and neurotransmitter production in CNS - Bradykinesia - Artificial dopamine: levodopa, carbidopa
Demographics  Difficulty in initiating movement, “rooted to the floor”  Many side effects
- 1.5 million in US - Rigidity - Other drugs to manage dopamine shortage, other symptoms
- 1% of people over 60 years  Flexors are tight, causes stooped postured, stiff facial - Physical, speech, occupational therapies
- 500,000 diagnoses each year muscles - Deep brain stimulation for tremors
- Men > women, 3:2 - Non-specific achiness, weakness, fatigue Medications
Etiology  Easy to miss this in elders - Levodopa, carbidopa
- Basal ganglia help control motor function - Poor postural reflexes - Catechol-O-methyltransferase inhibitors (prolong effects of L-
 They need dopamine  High risk of falling dopa)
 Dopamine is produced in substantia nigra Secondary Signs and Symptoms - Monoamine oxidase B inhibitors (protect some neurons)
- Substantia nigra cells die - Shuffling gait - Anticholinergics (manage rigidity)
 Produce less dopamine - Changes in speech and eating Massage Therapy Implications
 Basal ganglia doesn’t work - Changes in handwriting Risks: It is difficult for Parkinson disease patients to get on and off a
 Motor function is affected: balance between - Sleep disorders table. They may need assistance.
flexors/extensors is lost - Depression Benefits: Massage therapy may help with sleep, rigidity, anxiety,
- Not clear why substantia nigra cells die - Mental degeneration depression. It is often used by Parkinson disease patients.
 Lewy body accumulation? Clinical Features Options: Many people report better results with short, frequent
 Environmental exposures? - Tremors of the head; head bent forward; masklike facial sessions rather than longer ones less frequently.
 Mitochondrial dysfunction? expression; drooling; rigidity; stooped posture; weight loss; Research: Massage therapy helps with constipation, a frequent
 Genetics? tremor; bradykinesia; loss of postural reflexes; bone complaint of Parkinson disease patients. Various types of massage
demineralization; festinating gait have been seen to help with rigidity, tremor, gait, range of motion,
and quality of life.
- Focus on balance for resistance training

- PNF for stretching of flexors
- Parkinsons is a progressive disorder involving diminishing basal ganglia function. The disorder results in slow, increasingly difficult movement, accompanied by resting tremors and muscular rigidity
- Discovered by Dr. James Parkinson in 1817
- “Parkinson’s disease” can imply a known cause
- “idiopathic Parkinson’s disease” suggests an unknown cause
- Neurons use neurotransmitter dopamine
 Concentration decreases with age
- In Parkinsons, the supply of dopamine is diminished due to necrosis of the dopamine-producing cells in the substantia nigra
- Substantia nigra, located in the basal ganglia, communicate to the brain to control movements and balance
- Symptoms occurs when dopamine is diminishes to 60-80% in neurons and 80% in basal ganglia
- Occurs to people in mid to late 60s
 Young-onset Parkinsons occurs between 21-39 years of age
 Same symptoms EXCEPT with additional dystonia (twisting movements)
 Responds well to drug therapy and progresses more gradually
- 70% experience a tremor as the initial symptom
 Goes unnoticed for C but others notices
- Symptoms start unilaterally then progress to bilateral
 Start with: tremors, stooped shoulders, lack of swing in one arm when walking, muscular aches and cramps
 Continues with: forward head posture and hyperkyphosis, increased flexion of the elbows, hips and knees
 Fine motor skills (like writing) are lost, difficulty changing (buttons and zippers) and difficulty standing up
 These are the 1st signs of bradykinesia (initiating movement)
 Then rigidity, loss of postural reflexes and freezing phenomenon, unable to stop action
 2/6 symptoms must be present for diagnosis
- Cause of Parkinsons
 Unknown
 “Parkinsons-plus” syndrome presents with
 Repeated head trauma (boxing)
 Cerebrovascular accident
 Toxins (carbon monoxide poisoning, epoxy)
 Iatrogenic drug-induced (antipsychotic medications that block dopamine receptors)
 Pathologies
 Brain tumor, Huntington’s disease, Creutzfeldt-Jacob disease, Alzheimer’s, hydrocephalus
- Progressions
 Stage 1
 Unilateral
 Rigidity or tremors
 Can be treated with physiotherapy and massage
 Stage 2
 Bilateral
 Increased rigidity, tremors and bradykinesia
 Balance is NOT affected
 Treated with Levodopa (drug)
 Stage 3
 Increased tremors, rigidity and bradykinesia
 Balance and walking are now impaired
 Unsteadiness, dystonia and freezing
 Stage 4
 Bradykinesia increases
 Walking possible but assistance is required
 Effects ADLs
 Stage 5
 Loss of ability to function independently
 immobile
- Medical Treatment
 No cure
 Levodopa (L-dopa)
 Side effects: nausea, anorexia and dizziness
 With increased dose causes dystonia, altered behavior (hallucinations and confusion) and on-off phenomenon (effectiveness
 Only useful for the first 3-5 years
 Effectiveness diminishes due to symptoms worsening
 Can be combined with carbidopa (Sinemet) or benserazide (Prolopa)
 Facilitate medications reaching to the brain
 Combination side effects: nausea, low blood pressure and heart problems
 Brain surgery may be performed
 Physical occupational and massage therapy are incorporated
 Massage therapy increases body and postural awareness, encourages movement of the limbs, maintains tissue and joint health, reduces stress and offers a supportive and accepting environment
- Symptoms
 Bradykinesia
 Slow initiation and performance of movements
 Progresses to the loss of spontaneous movement including facial expressions, blinking and gesturing
 Rigidity
 Can affect all muscles
 Generally feels stiff and achy
 Like the C hasn’t stretched in years
 Causes “mask of Parkinsons” loss of facial muscles thus expression
 Dysarthria (tongue muscles) effecting speech
 Slow or soft monotone
 Difficulty articulating
 Excessive saliva and difficulty swallowing thus drooling
 Leads to embarrassment and social isolation and depression
 Upper limbs
 Increased muscle tone in the suboccipital and posterior cervical muscles
 Can cause headaches
 Increased tone in pectoralis and latissimus dorsi
 Can cause chest pain
 Increased tone in quadratus lumborum
 Can cause backaches
 Walking, eating, speaking, breathing and facial expressions may be compromised
 In the trunk can lead to compromised respiratory function
 Resting tremors
 Occurs most often in the hand
 Appear unilaterally
 May effect the same foot
 After 1-2 years affects bilaterally
 “pin rolling” tremor is the action of the thumb moving across the index and middle fingers
 Worse during rest/sleep
 Most debilitating aspect
 Breathing
 Rigidity in respiratory muscles leads to shallow breathing
 Risk of increased pneumonia and other pathologies
 Leads to dyspnea (difficult breathing), tachypnea (raid breathing), chest discomfort and involuntary grasping
 Fatigue
 Postural changes
 Forward flexion and lateral tilt of the trunk
 Forward head flexion
 Can lead to scoliosis and hyperkyphosis
 Contractures can occur
 Gait
 Less arm swinging
 Quick shuffling steps from not wanting to fall forward, festinating gait
 Challenge in changing directions or stopping
 Balance
 Retropulsion, making the person unable to stop from falling backwards
 Propulsion, making the person unable to stop from falling forward
 Ultimately leads to fall injuries
 Even while sitting
 Freezing phenomenon
 Inability to move
 Happens when person is distracted or interrupted
 Must relax and think
 Pain syndromes
 Results of biomechanics, postural imbalances and muscle disuse (ischemia)
 Results in cramping and spasm
 Sensory changes
 Hyperesthesia and pain when area is touched
 Autonomic dysfunction
 Salivation and sweating increases
 Leads to drooling
 Can cause eating problems
 Greasy skin around face and neck, but dry elsewhere
 Constipation
 Side effect of medication and hyperkyphosis
 Hypotension
 LBP while resting and well as standing (orthostatic hypotension)
 Drops 20-30 at rest and 10-20 during postural changes
 Speech
 Incoordination or decreased muscle movements
 Inability to write
 Small and cramped (micrographia)
 Depression
 Dementia
 Occurs in 40% of people (exaggerated, more like 10-15%)
 Pseudodementia and Alzheimer’s
- Assessments
 Observations
 Posture
 Forward flexion and lateral tilt of trunk (scoliosis, hyperkyphosis with posterior or anterior pelvic tilt)
 forward head flexion
 flexion of elbows, hips and knees
 Inversion of the feet with big toe dorsiflexion
 Resting tremors in hand or foot
 Unilateral or bilaterally
 Difficulty maintaining upright posture
 Lack of eye blinking
 Increased drooling
 Frozen facial expression
 Gait
 Movements appear stiff and rigid
 Less arm swinging
 Quick shuffling steps from not wanting to fall forward, festinating gait
 Challenge in changing directions or stopping
 Palpation
 May not be able to touch due to hyperesthesia (pain when area is touched)
 Rigidity in agonist and antagonist muscles
 Skin may be oily on the face and neck but dry elsewhere
 Range of Motion
 AROM decreased range of motion
 PROM resistance with flexors and extensors
 Lead pipe rigidity
 May be interrupted by tremor
 Most often occurs in wrist and elbow
 ISO not useful
 Special Tests
 Bradykinesia Tests
 Finger-to-nose test
 Heel to knee test
 Pronator drift test
 Sensory testing
 Specific orthopedic tests
 Rigidity may be present and tests are not able to be performed
- Contraindications
 Sympathetic nervous system firing should not be stimulates as this will increase the symptoms
 Prolonged vigorous or painful techniques should be avoided
 Areas sensitive to touch are avoided
 Pressure and hydrotherapy applicate are modified in areas of altered sensation
 Positioning, techniques and hydrotherapy are modified if hypertension is present
 Affecting predominate elderly increased BP and heart disease
 Hypotension is a threat as a result of autonomic dysfunction or as a drug side effect
 Care taken when C is changing positions (may not be able to)
 May need help getting on and off the table
- Treatments Goals
 Positioning (may not be able to change positions readily)
 Supine
 Pillow under trunk (make sure neck is supported) and legs
 Prone
 Cradle pillow change to encourage less forward head posture
 Side-lying
 Avoid curling of the trunk
 Anterior pillow may help (to hug)
 Pillow for waist if scoliosis present
 Cloth is kept for the client for drooling
 Hydrotherapy
 Caution for decreased tissue health and sensory loss, or hypertension
 Deep moist heat for relaxation and decrease muscle tone
 Edema, cool application and elevation
 Maintain proper alignment
 Maintain tissue health
 Maintain mobility
 Decrease rigidity
 Decrease tremors
 Provide emotional support
 Decrease edema
 Address postural changes and muscle imbalances
 Limit contractures
 Reduce constipation
 Address diaphragm muscles
- Self-Care Goals
 Maintain functional ability
 Improve flexibility, range of motion and posture
 Address ADLs, functional outcomes
 Educate client
- Treatment Frequency and Expected Outcomes
 Regular and ongoing
 One hr a week
Tremor
Tremor
Definition Types of Pathologic Tremor Treatment
- Involuntary oscillating movements on a fixed plane Essential Tremor - Several medications and/or moderate alcohol consumption can
- Can be freestanding, or part of another condition - Idiopathic, free-standing condition lessen symptoms
- Tremors vary by - Slowly progressive - Surgery if necessary
 Velocity - Potentially debilitating Medications
 Amplitude - Low amplitude, high frequency tremor - Beta-blockers
 Locations  More noticeable during activity than rest - Tranquilizers (benzodiazepine, phenobarbital)
Demographics Secondary Tremor - Antiseizure medication
- 10 million in US have essential tremor - Tremor is part of another CNS disorder - Botox injections
- Mostly among elderly, but can affect young people too  Parkinson disease - Controlled doses of alcohol
- Many be a genetic link  Multiple system atrophy Massage Therapy Implications
Etiology  Dystonia Risks: Be aware if tremor is connected to underlying problem. It
- Most tremors reflect a dysfunction in links between  Huntington disease may be necessary to help getting on and off the table.
 Brainstem Signs and Symptoms Benefits: Clients whose symptoms are exacerbated by stress may
 Cerebellum - Resting tremor: find that massage therapy is helpful.
 thalamus  Oscillation at rest, not during activity or sleep
- Usually affect hand, face, head - Action tremor:
- Physiologic:  Postural tremor – oscillation occurs when a patient
 Exacerbated by stress, fear, withdrawal, etc. tries to hold a limb out against gravity
- Pathologic:  Isometric tremor – oscillations occur with isotonic
 Idiopathic or caused by something else, i.e., Parkinson contractions
disease  Intention tremor – oscillations occur with the attempt
to do fine hand movements
- Psychogenic tremor:
 Everyone has it; too subtle to see
 Can be worse with stress
Infectious Disorders
Encephalitis
Encephalitis
- Infection of the brain - Range from mild to severe
 Usually viral  Depends on pathogen, general health of patient
 Can involve spinal cord (myelitis)  Very young and very old are most vulnerable
 Can involve meninges (meningitis) - Mild:
Demographics  Sudden onset of fever, headache, drowsiness, disordered thoughts
- Estimated to occur 20,000 times each year in US - Severe:
 Most cases are mild  Drowsiness progresses to stupor, coma; double vision, confused sensation, impaired
Etiology speech, convulsions, paralysis, changes in personality or intellect
- Usually a viral infection Treatment
 Primary or secondary - Antiviral, steroids to limit inflammation
- Affect parenchyma (working cells) of the brain, spinal cord, meninges - Sedative
- Usually not serious but can cause… - Rest, nutrition, adequate hydration
 Permanent damage Medications
 Cognitive changes - NSAIDs (not for infants)
 Stroke - Antiviral medications
 Seizures - Anti-inflammatories, steroids
 Paralysis - Antiseizure drugs
 Death - Sedatives
- Most common viral causes: Massage Therapy Implications
 Herpes simplex Risks: Acute infections need to reschedule massage regardless; fever, headache and confusion
 Herpes zoster together form a medical emergency.
 Flu Benefits: a person who has full recovered from encephalitis can enjoy massage with whatever
 Arboviruses accommodations might be needed for any long-term repercussions
 West Nile virus
 Dengue fever
 Enteroviruses
 Hepatitis A, B, C
 Polio
Herpes zoster
Herpes zoster
Definition Types of Herpes Zoster Signs and Symptoms
- Infection caused by varicella zoster virus (VZV) Chickenpox - Pain and itching
- Targets dendrites of sensory neurons in the skin - Usually the 1st exposure to VZV, usually in childhood - With chickenpox: whole body (sometimes internal as well)
 Leads to painful, fluid-filled blisters - Itchy blisters on a red base, all over the body - With shingles: along a specific dermatome, may be patchy
- First episode is usually chickenpox - Vaccine is available Treatment
- Subsequent episodes are usually shingles Shingles - Palliative treatment:
 “Girdle” or “belt”, marking the affected dermatome - Resurgence of VZV  Cool baths, soothing lotion
Demographics - Outbreak of painful blisters along a single dermatome  Analgesics
- About 95% of US adults are VZV+ Herpes Zoster Ophthalmicus Medications
 Means they could get shingles - Site of reactivation is the branch of the trigeminal nerve that - NSAIDs (not for infants)
- People vaccinated for chickenpox can also get shingles supplies the eye - Steroidal anti-inflammatories
 Happens more rarely  Conjunctivitis - Antiviral medications
- About 4% of adults will have shingles at some point  Corneal ulcers - For PHN:
 Especially among immune-suppressed  Inflammation of the eye  Opioid analgesics
 Diagnosed about 1 million times/year  Temporary or permanent vision loss  Tricyclic antidepressants
 Can occur multiple times Postherpetic Neuralgia  Antiseizure medication
Etiology - Pain outlives the infection  Topical lidocaine, capsaicin patches
- VZV (a herpes virus) attacks sensory nerve cells receivers  Minimum of 3 months, could persist for years Massage Therapy Implications
 Painful, itchy blisters - Risk increases with age Risks: People with this acute infection are likely to cancel
 Spread through mucous secretions  60% of 60-year-old patients with shingles get PHN appointments; touch is not usually welcomed. Risks center on pain
- After 1st chickenpox, the virus goes dormant in dorsal root  75% of 70-year-old patients with shingles get PHN and communicability, but most people have immune system
ganglia or trigeminal nerve Zoster Sine Herpete protection.
- Reactivated when immune system is low as shingles - Reactivation of the virus, no visible lesions Benefits: A person who has fully recovered from herpes zoster of
- Contributing factors: - Easily misdiagnosed as internal problem any kind can enjoy the benefits of massage. A person with
 Age Ramsay Hunt Syndrome postherpetic neuralgia may find massage to be soothing.
 Stress - Infection of facial and auditory nerves
 Impaired immunity  Hearing loss
- Only contagious to immune-suppressed, or chickenpox-naive  Temporary or permanent facial paralysis
 Looks like Bell palsy
Meningitis
Meningitis
Definition Types of Meningitis
- Inflammation of the meninges in brain and spinal cord Bacterial Meningitis
- Usually affects the pia mater and arachnoid: leptomeninges - Usually pneumococcus, meningococcus
- Does not involve nerve tissue - Often more severe than viral infections
 If nerve tissue is involved, it might be called meningoencephalitis or meningomyelitis  Higher risk of long-term complications
Demographics  Antibiotic-resistant infections are a new challenge
- Usually among 3 groups Viral Meningitis
 Children under 5 years old - Many types
 Young adults living in close quarters - Less severe than bacterial meningitis, seldom causes permanent damage
 Elderly people  In young children the risk is higher for several serious complications
- Viral meningitis: about 10,000 documented cases/year in US Treatment
- Bacterial meningitis: about 4,100 cases/year, 510 deaths - Vaccine for most common bacterial meningitis (HiB)
Etiology - Some vaccines for viruses are available, not necessary unless traveling to areas where infections
- Usually viral or bacterial are endemic
 Rarely fungal or amoebic - For bacterial meningitis; antibiotics, anti-inflammatories
- Infections in the cerebrospinal fluid can… - For viral meningitis: antiviral medication, anti-inflammatories, supportive therapy
 Cause cerebral edema Medications
 Allow wastes to enter the CNS - Oral/intravenous antibiotics
 Damage cranial nerves through pressure - Antiviral medication
 Especially CN VIII, leading to hearing loss - Steroidal anti-inflammatories
 Cause obstructive hydrocephalus - Antiseizure medication
 Several other serious problems Massage Therapy Implications
- Pathogens may concurrently infect other parts of the body Risks: All meningitis infections systemically contraindicate massage while acute, for reasons of pain,
- Bacterial infections of the brain and body can cause a signature purple rash, clotting, risk of weakness, and communicability.
gangrene Benefits: Clients who have fully recovered from meningitis can enjoy all the benefits of massage
- Bacterial meningitis is spread through respiratory secretions therapy.
- Enterovirus meningitis is spread through oral-fecal contamination
- Meningitis can be a complication of trauma or surgery
Signs and Symptoms
- Rapid onset of fever, chills
- Deep red, purple rash
- Extreme headache
- Aversion to bright light
- Stiff neck (moving the neck stretches the meninges)
- Confusion, drowsiness, slurred speech
- Nausea
- Convulsions
- Incubation can take hours to weeks; symptoms last about 2-3 weeks
Polio, postpolio syndrome
Polio, postpolio syndrome

- AKA “infantile paralysis” - Postpolio syndrome:
- Viral infection  Sudden, extreme onset of pain, weakness, fatigue
 Begins at intestinal mucosa  Spondylosis, postural deviations
 Travels to anterior horn of the spinal cord  Decreased tolerance for cold
- Rare as new infection  Breathing problems, sleep disturbance, trouble swallowing…
- Many survivors still at risk for postpolio syndrome: progressive weakness that develops 10-40 years  Flares with lost function, periods of stability, more flares…
after initial infection Treatment
Demographics - Moist heat, physical therapy, massage
- About 1.6 million in US have had postpolio syndrome  May help keep functioning muscle fibers healthy
- Women > men - Reduce muscular and neurological stress
- Usually identified 30-35 years after initial infection  Adjust assistive equipment
Etiology  Change activities
- Wild virus is usually spread through oral-fecal contamination  Avoid exercising affected muscles
- 99% of those exposed have no symptoms after minor gastritis Massage Therapy Implications
- 1% have viral attack of motor neurons in anterior horns of the spinal cord Risks: Risks of working with someone with an acute infection are very low. Otherwise it is simply
 Impedes motor signals necessary to respect any weakness or fragility that each client presents.
 Leads to muscle atrophy, motor paralysis Benefits: Postpolio syndrome may respond well to massage that focuses on sleep, reducing fatigue,
- Paralysis only affects motor neurons; sensation stays intact and preparing muscles to work efficiently, without unnecessary tension.
- Overlapping motor supply means extremities retain some function Research: Many patients with postpolio syndrome use massage therapy and acupuncture to help
- Surviving neurons grow new axon terminals, increase the size of each motor unit manage symptoms.
 Eventually these wear out – leading to postpolio syndrome
- Thanks to 2 effective vaccine, polio is now very rare
 Virus may be present in fecal material of recently vaccinated infants; immune-
compromised people should be aware of this
- Hand to knee gait

- Later splint to stop gait, but leads to overworked QL
- Poliomyelitis is an acute viral infection specifically affecting the motor neurons in the spinal cord and brain stem
 Results in flaccid paralysis and muscle weakness
 Caused by a virus, most common viral infection
 Vaccine was developed in 1955
 Clinically rare
 Most polio infections now end in full recovery
 Paralysis is rare in children but adults increases
 Enters the system through direct contact
 Mouth  lymphatic system
 During initial stage only slight temperature and flu-like symptoms
  GI tract or sympathetic pathways
 Destroys anterior horn cells (motor cells) in the spinal cord but leaves sensory cells intact
 Leads to necrosis of motor cells followed by local inflammation of the meninges
 Symptoms progress to severe headaches along with intense muscular pain and stiffness
 Particularly in neck and back
- Types of Polio
 Several types can lead to paralysis
 Most common type is spinal poliomyelitis
 Inflammation and destruction of the anterior horn cells
 Occurs at any level of the spinal cord
 Most severe is bulbar poliomyelitis
 Involves cranial nerves and sometimes cardiorespiratory centre
 Mortality rate is higher because of the failure of the medulla which control respiratory muscle
 Non-paralytic polio involves flu-like symptoms and meningeal irritation
 Paralytic polio the symptoms progress further
- Symptoms for Paralytic Polio
 Over 3-5 days flaccid weakness presents in the muscles
 Proximal legs
 Due to necrosis or compression from inflammation
 Peripheral nerves that are compressed by inflammation may recover
 80% good or full recovery
 Permanent function loss occurs in areas of necrosis
 Reflexes are also lost
 In children may stunt growth causing limb shortness
 Flaccid tissue is replaced by fibrous or fatty tissue
 Muscle imbalances could lead to contracture and postural deformities (ex. scoliosis
 Joint pathologies can also develop (ex. osteoarthritis, tendinitis, bursitis and sprains) from poor biomechanics
- Post-Polio Syndrome
 Occurs after the person has been stable for years (decades)
 Risk in those who contract it as adults, had severe case and those who are overly active after recovery
 20-25%
 Cause is unknown
- Symptom Picture for Post-Polio Syndrome
 Mild to seriously disabling
 Slow, progressive weakness in the muscles previously affected that were thought to have full recovery
 Muscle cramps, weakness and joint pain
 Contractures, and joint and soft tissue conditions can increase postural deformities, cause loss of functional ability
 Dysarthria (difficulty with speech, muscular), dysphagia (difficult with speech, brain/CNS) and respiratory difficulties (ex. apnea, from respiratory centres in the brain/CNS)
- Contraindications
 Decreased tissue health may contraindicate deep or vigorous techniques to flaccid atrophied muscles
 If arthritis is present, joint play and overpressure are modified or avoided
- Assessments
 Postural assessment
 Look for compensation patterns
 Testing for length and strength
 If there are contractures
 Also to see what synergist is more functional
- Massage Therapy
 Flaccid or muscle atrophy results in contracture formation in unopposed antagonist muscles
 Synergist muscles compensate and are overworked
 Depends on severity could be a small group of muscles or an entire limb
 Frequently involve tibialis anterior and posterior, the peroneals, quadriceps and gluteus medius
- Treatment Goals
 Hydrotherapy
 Deep moist heat  facial techniques, overpressure and stretches
 Maintaining tissue health
 Range of motion
 Strength of compensating muscles
 Reduce stress
 Reduce pain
 Reduce anxiety
 Improve ADL
 Postural awareness
 Reduce contractures
Psychiatric Disorders
Addiction
Addiction
Definition Risk Factors Signs and Symptoms
- An arc of three patterns of substance use: - Genetic predisposition - Person feels a persistent craving
 Use - Other mental illness - Person goes to great—even illegal—lengths to secure access
 Ingesting a substance specifically to change mood - Environmental factors - Person cannot voluntarily control use
or physical experience - Type of drug - Person has developed tolerance; needs more substance to feel
 Abuse - Age “normal”
 Use of a substance in a way that is potentially - Medical reasons - Person puts themselves or others at risk while under the
harmful to the user or to people close to the user Complications of Drug Addiction influence
 Use leads to impairment of function, other criteria - Range from inconvenience to paranoid delusions, coma, death - Cessation of use produces alarming, dangerous withdrawal
 Use of a substance out of context (i.e., stealing - Risks also affect people close by: family, coworkers, etc. symptoms
prescription drugs, sniffing glue) Complications of Alcoholism Treatment
 Dependency – three or more are true: - Digestive system: - Person must acknowledge the problem, or treatment won’t
 User develops increasing tolerance  Gastritis work
 User has withdrawal symptoms when use is  Liver damage, cirrhosis - Detoxification
suspended  Cancer - Rehabilitation
 User uses increasing amounts of the substance  Ulcers - Aftercare (most important phase)
 User cannot voluntarily limit use  Pancreatitis - Some medications can reduce cravings
 User replaced other activities with substance use - Cardiovascular system: Medications
 Use continues this behavior, even with knowing the  Decreases force of heartbeat - Benzodiazepine to mitigate withdrawal symptoms
dangers involved  Irregular heartbeat, arrhythmia - Neurotransmitter receptor blockers
Demographics  Cardiomyopathy - Disulfiram (creates negative physical response to alcohol use)
- Estimate: 5-17% of US population has a substance abuse  Agglutination of blood cells, thrombi Massage Therapy Implications
problem  Reduced clotting factors, bleeding Risks: A person with a history of addiction may also have secondary
- Use of illegal drugs is dropping; use of stolen prescription drugs - Nervous system: health problems, including infections and heart problems. These
is rising  Blocked cerebral capillaries, starved brain cells need to be accommodated.
- Alcohol abuse is major cause of illness and death in US  Slows reflexes, slurs speech, impairs judgement Benefits: Massage Therapy may help with withdrawal symptoms
 Contributes to 10% of adult premature deaths,  These can become permanent and to lessen the need for tranquilizers
88,000/year  Advanced cirrhosis can cause brain damage Options: Current use at the time of an appointment is a caution
Etiology - Reproductive system: mainly because of the risk of overtreatment and toxicity—people
- Process of developing dependency depends on substance,  Reduced sex drive may be sick
vulnerability of the user  Erectile dysfunction Research: Massage therapy has been used to soften withdrawal. It
 Many drugs change the way neurotransmitters and  Menstrual irregularities may help with anxiety, general coping skills for some people.
receptors function  Fetal alcohol syndrome
 We grow more receptors; we need more chemicals to - Families:
fill them up  Children have increased risk of being substance abusers
 Some people are genetically predisposed for addition  Risk of
- Alcohol and sedative depress CNS arousal  Depression
- When dependency is established:  General anxiety disorder
 It takes more substance to achieve the desired effect  Phobias
 Withdrawal symptoms interfere with cessation  Higher health costs
Types of Addiction  Many children end up in foster care
Psychological addiction - Other:
- The user loves how s/he feels under the influence  Alcohol is a frequent factor in…
Physical addiction  Traffic injuries
- The user hates withdrawal symptoms; will do anything to avoid  Drownings
them  Falls
 Withdrawal symptoms can include pain, hallucinations,  Burns
nausea, vomiting, seizures, death  Shootings
Anxiety Disorders
Anxiety disorders
Definition Panic attack, panic disorder Separation anxiety
- Collection of distinct psychiatric disorders centered on irrational - Sudden onset of extreme sympathetic response symptoms - Associated with young children
fears  Pounding heart - Often missed in adults (occurs with other disorders)
- Often overlap  Chest pain - Can be debilitating
- Range from mild to completely debilitating  Sweatiness - Can limit treatment success for other anxiety disorders
Demographics  Dizziness Signs and Symptoms
- Estimate that up to 40 million people in the US have some sort  Faintness - Vary according to type
of anxiety disorder; only a small portion of them are treated  Flushing/chilling Treatment
Etiology  Hyperventilation - Usually a combination of medication and psychotherapy
- Interpretation of environment leads to constant questioning of  Feeling of impending doom - Some respond better to psychotherapy and help with coping
basic safety  10 minutes to several hours skills; not to medication
- Contributing factors: - Repeating episodes = panic disorder - Most can be successfully treated, if the patient has access to
 Genetics - Can complicate to agoraphobia, which is harder to treat care
 History of traumatic events Agoraphobia - Psychotherapy:
 Situations that form triggers - Happens in about 1/3 of people with panic disorder  Controlled exposure to frightening stimuli
- Arousal: - Defined as “fear of open spaces”  Behavioral-cognitive therapy
 Preparation for possible stressful events - Better description is “Fear of any place a panic attack might  Etc…
- Fear: occur” - Also
 Stressful event is confirmed - Safety zone progressively shrinks  Relaxation, meditation, yoga, massage therapy
- Anxiety: Phobias Medications
 No discernable threat, but constant preparation for Social phobia - Antidepressants; anti-anxiety drugs; beta-blockers
disaster - AKA social anxiety disorder  Antidepressants include:
- Can make it impossible to participate in society - Tense, irrational fear of being judged  SSRIs, tricyclics, MAO inhibitors
- Increased risk for several other conditions - Can be debilitating  Benzodiazepines for sedation (risk of dependence)
- Part of the picture is neurotransmitter imbalance - Symptoms develop in childhood  Buspirone for sedation
 Serotonin  Blushing  Beta-blockers for symptoms of panic disorder
 Dopamine  Sweating Massage Therapy Implications
 Norepinephrine  Trembling Risks: Some patients may have a history of abuse that makes
 GABA  Nausea receiving massage a trigger. It is important that people feel safe in
Types of Anxiety Disorders - Women > men the massage therapy environment.
General anxiety disorder Specific phobias Benefits: Massage therapy may help clients feel calmer, more able
- Constant anticipation of disaster - Intense, irrational fear of something that poses little real to cope with day-to-day stressors
- Does not limit activities, does limit quality of life danger Options: Be flexible to meet these clients’ special needs; they may
- Symptoms: 6 months + of…  Specific animals, including insects and spiders need to stay dressed, have another person in the room, etc.
 Restlessness  Closed in spaces (claustrophobia) Research: Massage has been shown to be effective for anxiety as a
 Begin on edge  Heights (acrophobia) free-standing disorder, and as a reaction to stressful situations like
 Fatigue  Flying surgery.
 Poor concentration  Elevators
 Irritability  blood
 Muscle tension - Can limit work and living situations
 Sleeping problems
Attention Deficit Hyperactivity Disorder
Attention deficit hyperactivity disorder

- Neurodevelopmental disorder - Inattentiveness - Psychostimulants
- Difficulties with  Easily distracted  Methylphenidate
 Attention  Poor attention to detail  Dextroamphetamine
 Movement  Careless mistakes - Norepinephrine reuptake inhibitors
 Impulse control  Losing items - Antidepressants
Demographics - Hyperactivity - Side effects can be a concern
- 5-8% of children in US  Restlessness, fidgeting  Appetite suppression
- About ½ of them will have symptoms that persist to adulthood  Difficulty waiting to participate  Increased blood pressure, heart rate
- Distribution between boys and girls is hard to guess because it - Impulsiveness  Sleep problems
is less disruptive in girls so they are often missed  Running, climbing, walking away when other behavior  Tics
Etiology is expected - Untreated ADHD also has risks
- Neurochemically mediated disorder Treatment  Substance abuse, etc.
 Dopamine, noradrenaline disruption - Diagnosis may be confounded by comorbid… Massage Therapy Implications
 Frontal cortex, basal ganglia, cerebellum: areas for  Sleep disorders; oppositional defiant disorder; Risks: No particular risks, but some people may not like a lengthy
decisions and movement depression; anxiety disorders session.
- Contributing factors - Psychostimulant drugs Benefits: Some symptoms appear to be less prominent in people
 Genetic predisposition  Stimulate areas in the brain where activity is who have ADHD who receive massage.
 Altered brain function diminished Options: Some clients with ADHD enjoy slow, subtle bodywork;
 Maternal behaviors, exposures during pregnancy - Norepinephrine reuptake inhibitors others prefer fast-paced, rigorous massage.
 Early childhood stress responses  Keeps norepinephrine in synapses for longer Research: Some improvements seen when children with ADHD
- Most successful treatments = meds + family support and receive massage include better focus at school, better sleep, better
training anger control.
Autism Spectrum Disorder
Autism spectrum disorder

Definition Types of Autism Spectrum Disorders Treatment
- Developmental disorder characterized by problems with… Autistic disorder - Depends on type, individual needs of the patient
 Interpersonal interaction - AKA “severe autism” - Applied behavioral analysis:
 Communication  Impairment in communication skills  Intense 1-on-1 therapy
 learning  Poor social interactions - Sensory integration therapy
- Shows as…  Restricted, repetitive patterns of movement - Treat other conditions
 Inability to emotionally connect with others Asperger Syndrome  ADHD, obsessive-compulsive disorder, depression
 Communication problems - At the mild end of the spectrum - Some dietary adjustments
 Restricted interests - Language, mental development are normal - Medication for seizures, anxiety, depression as needed
 Specific, predictable movement patterns - Social skills are lacking Medications
 Sensory problems - May have consuming interest in a single topic - Antipsychotics for anger, aggression
Demographics - Some suggest that Asperge syndrome is a distinct entity from - Antidepressants
- Numbers have been climbing mild autism, but not all agree - Psychostimulants
 Could be that it is more common Pervasive Developmental Disorder, not otherwise specified - Anti-seizure drugs
 Could be that it is more accurately recognized - A child displays several signs of being on the spectrum, but in Massage Therapy Implications
- US estimate is 1:88 children an unusual pattern Risks: The sensation of touch is not always welcomed. Be patient
 400,000 are on the spectrum now Signs and Symptoms and flexible about this.
Etiology - Vary according to type and severity Benefits: If a client is comfortable, profound change sin sensitivity
- No predictable brain abnormalities - 3 common patterns: and the potential for person connection can occur
- Factors:  Deficits in verbal, nonverbal communication Options: The client must feel in charge of the session; otherwise it
 Fragile X syndrome: inherited mutation  Problems with social interactions will be extremely unpleasant for her or him.
 Tuberous sclerosis: inherited mutation  Repetitive behaviors, movements Research: Most research support massage therapy for people on
 Other genetic anomalies—tends to run in families - Also… the autism spectrum, more studies with rigorous standards must be
 Unpredictable reactions to sensory stimuli conducted to get definitive information.
 May be insensitive to temperature
 Hypersensitive to sound, texture
Bipolar Disorder
Bipolar disorder
Definition Types of Bipolar Disorder Treatment
- AKA manic depression Bipolar Type I - Requires mix of medications to address both mania and
- Marked by mood swings from major depression to mania - Most common form depression
Demographics - Diagnosed when…  One without the other can trigger an episode
- Affects about 2.6% of US adults  Manic for 1 week - Drugs may have unpleasant side effects, bad interactions with
 2.3 million people  Depressive for 2 weeks other medications
- Of those affected, 83% have a severe form - Hospitalization, impaired social function - Mood-stabilizing drugs based on lithium, plus antidepressants
- Often appears in late adolescence - Psychotic delusions and hallucinations in mania and depression Medications
- Men = Women Bipolar Type II - Mood stabilizers
 Men are more likely to be misdiagnosed with - Milder form  Lithium, lithium analogues
schizophrenia - Mood swings from mild depression to hypomania  Can be toxic
 Women are more likely to be misdiagnosed with major - No psychosis  For mania
depressive disorder - No impairment on social function - Antidepressants
Etiology Cyclothymia  For depression
- Etiology is not well understood - Type II mood swings that last for 2 years or more - Anticonvulsants
- Appears to run in families Mixed Bipolar Disorder  For mania
- Differences in brain development during adolescence may - Some manic and depressive symptoms - Antipsychotics
trigger symptoms  Simultaneously  For hallucinations, delusions
- Demyelination in areas of the brain that manage emotion  Quick succession Massage Therapy Implications
Signs and Symptoms - Extremely disruptive Risks: Two issues: side effects of medications may make the client
- Manic phase: Rapid-Cycling Bipolar Disorder feel lethargic, irritable; the client-therapist relationship must be
 Heightened energy, elation - Very severe carefully tended.
 Irritability - 4+ cycles each year Benefits: People with bipolar disorders need to maintain healthy
 Racing thoughts social relationship. Conceivably massage therapy could be one path
 Increased sex drive toward doing that.
 Decreased inhibition
 Unrealistic, grandiose ideas
 Poor judgement
- Depressive phase:
 Signs and symptoms of major depressive disorder
Depression
Depression
Definition Types of Depression Treatment
- Group of disorders wit negative changes in mood state Major Depressive Disorder - Most cases are treatable
- “A genetic neurochemical disorder requiring a strong - Classic example  Finding the right treatment can be difficult
environmental trigger whose characteristic manifestation is an - Severe symptoms persist for 2 weeks or more - Medications may require several weeks to take effect
inability to appreciate sunsets” – Sapolsky - Episodes may last 6-18 months  Side effects in the meantime
- Main factors:  Recur 4-6 times over a lifetime (adds up to 10 years or - Important to treat fully to prevent complications, recurrent
 Genetic predisposition more) episodes
 Chemical changes - Each episode may be triggered by a smaller event - Talk therapy, including
 Triggering event Persistent Depressive Disorder  Cognitive-behavioral therapy
 Inability to experience pleasure - Depressed mood for 2 years or more  Interpersonal therapy
Demographics - Less severe than major depressive disorder, longer lasting  Psychodynamic therapy
- 20% of women in US - AKA dysthymia - Other treatments:
- 12% of men in US Psychotic Depression  Light therapy (especially for SAD)
- Highest 25-45 years old - Major depressive disorder with psychosis  Electroconvulsive therapy
Etiology  Hallucinations (distortions of perception)  St. John’s wort
- Not well understood  Delusions (beliefs that are not changed by reason or  S-adenosyl-methionine (SAM-e)
 Neurotransmitters, especially serotonin, dopamine, contradictory evidence)  Omega 3 fish oil
norepinephrine Seasonal Affective Disorder  5-hydroxytryptophan
 In short supply, or receptors are unreceptive - Depression related to lack of sunlight  Transcranial magnetic stimulation, vagus nerve
 Medication works to make them more available - Incidence related to distance from the equator stimulation
 Hypothalamus-pituitary-adrenal axis (HPA axis) - May be related to low melatonin Medications
 Depressed people appear to have more stress Premenstrual Dysphoric Disorder - Antidepressants work to keep key neurotransmitters present in
responses to smaller triggers with more prolonged - Types of premenstrual syndrome that includes signs of major synapses for as long as possible
effects than others depressive disorder with monthly cycles  Selective serotonin reuptake inhibitors
- Other factors: Postpartum Depression  Serotonin norepinephrine reuptake inhibitors
 Personal chemistry - Affects new mothers, within a few months of giving birth  Tricyclic antidepressants
 Genetics  Vast hormonal shifts  Monoamine oxidase inhibitors (have potentially
 Environment, emotional triggers  Inadequate social support dangerous interactions, requires special care
 Personality and emotional resilience  Biologic vulnerability - Anti-anxiety medication may also be used
 Often overlaps other disorders - Symptoms of major depressive disorder with fear of harm or Massage Therapy Implications
 Treating depression may make treating other doing harm to the baby Risks: No specific physical risks, but tend the therapist-client
conditions more successful - Postpartum psychosis is different: involves hallucinations and relationship carefully. Clients may want to go off medication if they
Complications delusions that may put mother and child at risk feel massage therapy helps; they must do this with the assistance
- Suicide risk Signs and Symptoms of their physician
 30,000 successful suicides/year in US - Depends on type Benefits: Massage appear to improve mood, anxiety and the sense
 200,000 attempts - Mainly: of the ability to cope with life stressors.
 About ½ are related to depression  Sad, empty feeling Research: Massage has been shown to help with depression as a
 Men have depression less often, but are more likely to  Not experiencing pleasure, enjoyment freestanding disorder and as part of chronic diseases.
commit suicide - Also…
- Risk factor for…  Guilt, disappointment
 Addiction  Hopelessness
 Stroke  Irritability
 Heart attack  Change in sleeping habits, change in eating habits
 (Also a predictor for recovery)  Decreased ability to concentrate
- Can make other chronic conditions worse  Loss of energy
 General pain
 Suicidal ideation
Eating Disorders
Eating disorders
Definition - Binge-eating disorder Signs and Symptoms
- Unhealthy eating habits that can be difficult to reverse  Cardiovascular disease - Depends on types
- Often a response to emotion, physical stressors  Osteoarthritis - Anorexia:
Demographics  Type 2 diabetes  Fear of gaining weight; distorted self-perception; loss
- Most anemia and bulimia patients are young women  Gallbladder disease of menstrual cycle
- Statistics on binge-eating disorders are not gathered - More easily reversed than anorexia and bulimia  Advanced cases have downy hair: lanugo
Etiology Types of Eating Disorders - Bulimia:
- Anorexia/bulimia patient profile: Anorexia Nervosa  Recurrent episodes of binge eating couples with
 Adolescent, young adult - Self-starvation: not enough calories to sustain life potentially dangerous compensatory activities
 High expectations, over achiever  Restrictive - Binge-eating disorder:
 Athletes in sports that emphasize thinness or low  Purge-type  Bouts of uncontrollable, rapid eating at least 1 week for
weight  Compensatory activities include: 3 months or more
 Often centers on control issues  Vomiting  Sense of distress, powerlessness
 Neurotransmitter changes contribute  Laxative use Treatment
- Binge-eating profile  Diuretics - Most successful when it not centered on food, but on control
 Not age specific  Enemas  Address psychological and emotional issues first
 Also involves lack of sense of control  Excessive exercise - Some people may respond to antidepressants, anti-anxiety
 Could involve touch deprivation Bulimia Nervosa medications along with talk therapy
 Could be response to abuse - “Ox hunger” Medications
Complications - Appears to eat normally in public - Antidepressants
- Anorexia, bulimia: - Binges on indulgent food in private - Mood stabilizers
 Depression - Follows with compensatory activity - Anti-seizure drugs
 Sleep disorders  Vomiting Massage Therapy Implications
 Anxiety disorders, obsessive-compulsive disorder  Laxative use Risks: Advanced anorexia or bulimia may compromise several
 Slow heart rate, low blood pressure, arrhythmia  Diuretics systems; make adjustments for frail clients. The main risk for
 Female athletic triad:  Enemas overweight clients is their concern about being judged; create an
 Disordered eating + menstrual dysfunction + low  Excessive exercise environment where all body shapes are welcomed with
bone density Binge-Eating Disorder unconditional positive regard.
 Overuse of laxatives - A person overeats in a short-term binge accompanied by a Benefits: Massage is a way to experience one’s body as safe, strong,
 Tooth damage from vomiting distressing sense of lack of control and healthy: good input for people who live with these disorders.
- May be mitigated by exercise, dieting Research: These often overlap anxiety disorders than tend to
 Unsuccessful attempts may trigger further bingeing respond well to massage therapy. The level of trust between the
episodes client and therapist must be high for any work to be effective
Obsessive-compulsive and related disorders
Obsessive-compulsive and related disorders

Definition - Examples of compulsions: Trichotillomania
- Conditions that used to be classified as anxiety disorders  Hand washing - Hair-pulling
- Now considered unique due to predictable patterns of  Refusing to touch things - Closely related to excoriation disorder
preoccupations and repetitive behaviors  Repeatedly checking locks, light switches, on/off - People feel anxious, pull at head hair, eyebrows, beard hair,
Demographics buttons, etc body hair
- About 2.2 million US adults  Counting things (i.e., telephone poles) - Sometimes complicates to hair-eating
- Men = Women  Repeating words, phrases, prayers Treatment
Etiology Body Dysmorphic Disorder - Combination of psychotherapy + medication
- Focus on unwelcome thoughts/repetitive behaviors - Extreme unhappiness, anxiety because of a real or imagined - Exposure/response prevention
- Etiologies vary… flaw Medications
 Family tendency - Beyond insecurity—impacts ability to be able to function in - Antidepressants
 Triggered by a specific event society - Anti-anxiety medication
 Some problems with serotonin production or uptake - Can lead to other OCD-type disorders, depression Massage Therapy Implications
Types of Obsessive-Compulsive and Related Disorders Excoriation Disorder Risks: Be aware of the client’s triggers, and work to accommodate
Obsessive-Compulsive Disorder - AKA skin-picking disorder them. Extra care in communication is essential
- Combination of - Picking at the skin, especially on or near the face, to the point Benefits: Welcomed massage therapy may help with a sense of self-
 Intrusive, unwelcome thoughts (obsessions) of self-injury (which leads to more picking) efficacy, ability to cope.
 Rituals to try to control thoughts (compulsions) - Efforts to stop are unsuccessful Options: be flexible, imaginative, and versatile to meet the special
 Many hours invested every day - Can impair social functioning needs of these clients
- Examples of obsessions: - Infection, permanent scars are frequent Research: Massage therapy is well accepted as a useful intervention
 Fear of contamination (dirt, germs, sexual activity) for anxiety disorders in general; OCD and related disorders could be
 Fear of violence, accident; fear of committing violent or considered part of this group.
sexual acts
 Fear of disorder, asymmetry
Trauma- and stressor-related Disorders
Trauma- and stressor-related disorders

Definition Signs and Symptoms Adjustment Disorder
- Collection of conditions previously called anxiety disorders - 4 types of symptoms: - Acute or chronic reaction to a stressor, can be a precursor to
- Different diagnostic criteria, so now considered free-standing  Re-experiencing PTSD
- Some suggest that PTSD should be called posttraumatic stress  Flashbacks, nightmares Reactive attachment Disorder
injury (PTSI) to lessen the stigma  Avoidance - Childhood stressor interferes in future coping skills
Demographics  Efforts to avoid stressful thoughts, situations - Pathologically withdrawn, inhibited
- Can develop at any age  Negative beliefs and mood - Reduced response to environment
- Special criteria in children  Self-blame, lack of trust, feeling alienated from - Poor self-care
 4% of boys / 6% of girls others Treatment
- About 30% of people who have been in war zones  Arousal - Combination of group, individual, family therapy
- Women appear to be more susceptible than men  Hypervigilance, poor sleep, aggressive behavior, - Medication
Etiology exaggerated startle response - Best if instituted early
- A life-threatening event can change brain function Types of Trauma- and Stressor-Related Disorders - Frequent overlap with addiction, depression—these must also
 Sympathetic and hormonal changes become persistent Posttraumatic Stress Disorder (PTSD) be treated
 Normal inhibitors don’t work - Experienced by a person exposed to Medications
- Factors:  Death - Antidepressants
 How close the event was; how long it lasted, how  Actual or threatened injury or violence - Beta-blockers
severe it was  Could be a participant or live witness - Sleep aids to decrease nightmares, sleep disturbances
 Characteristics of the person - Also affects… Massage Therapy Implications
 What happens in the posttraumatic period  Relative, people close to the person in trauma Risks: Main risk is triggering a flashback or other reaction. In the
 First responders and caregivers event of a dissociative episode, stay present and attentive; try to
Dissociative Posttraumatic Stress Disorder bring the client back to the present.
- Person who feels detached from their mind and/or body Benefits: Massage may be helpful for people with PTSD and related
- The world seems unreal, distorted disorder to feel better connected to themselves and their world. It
- (this distinction calls for different treatment options) is an important exercise in trust.
Acute Traumatic Stress Disorder Research: If people are comfortable with touch, research shows
- Looks like PTSD that massage therapy can be a helpful addition for people with
- Develops more quickly after the event PTSD and survivor of other ordeals
Nervous System Injuries

Bell Palsy
Bell palsy
Definition Complications
- Result of damage to CN VII, the facial nerve - If blinking is impaired, the eyeball may be damaged
 Main motor nerve for the face: - Sometimes the facial nerve makes weird new connections:
 Facial expression  Synkinesis = secretion of tears during salivation
 Blinking Signs and Symptoms
 Some taste sensation - Sudden onset of flaccid paralysis of 2 side of the face
- Usually temporary - Difficult to eat, drink, close eye
Demographics - Production of saliva changes (more or less)
- Diagnosed about 40,000 times/year in US - Taste may be distorted
- Mostly among - Hyperacusis
 Pregnant ladies - Motor paralysis, but sensation is intact
 People with diabetes Treatment
 People who recently had a cold or flu - Depends on causative agent
Etiology  Can be related to other disorders, tumors, etc.
- Type of peripheral neuritis - Usually conservative treatment
- CN VII travels through several narrow spaces  Steroidal anti-inflammatories
- Inflammation can damage it in these areas  Antiviral medication
- Factors  Tape the eye shut at night, use drops for lubrication during the day
 Herpes simplex can inflame CN VII Medications
 Lyme disease - Steroidal anti-inflammatories to manage nerve inflammation
 Epstein-Barr virus - Antiviral medication
 Cytomegalovirus - NSAIDs for pain relief
- Ranges from mild to severe Massage Therapy Implications
- Starts with myelin damage Risks: No risks unless an underlying condition poses some concerns.
- Can penetrate to the nerve fibers Benefits: Massage may help keep muscles elastic and set the stage for a more successful recovery.
- Leads to weakness, flaccid paralysis of 1 side of the face Research: Many experts recommend massage based on anecdotal rather than clinical findings.
- Prognosis if good Research suggests that it may be helpful and has very low risk of causing harm.
 85% regain full or nearly full function
- Could lead to false positive for jaw reflex because temporalis and masseter is part of the trigeminal nerve 5
- Bell’s palsy is a condition involving a lesion on the facial nerve (cranial nerve 7). It results in flaccid paralysis of the muscles of facial expression on the same side as the lesion
- One of the most common neurological conditions
 25% of 100,000
- Facial nerve leaves the brain stem and passes through ganglion before it separates into 2 divisions
 1 division is the motor nerve
 It travels through the petrous canal of the temporal bone before exiting at the stylomastoid foramen
 Travels through the parotid glands where it then gives off 5 branches to supply motor function/facial expression
 Temporal branch to orbital (eye) and forehead muscles EXCEPT the levator palpebrae superioris (which opens the eye is supplied by Cranial Nerve 3)
 Zygomatic branch supplied the zygoma, orbital and intra-orbital area
 Buccal branch to the buccinator and upper lip muscles
 Mandibular branch to the lower lip and chin muscles
 Cervical branch to the platysma, stylohyoid and posterior digastric muscles
 2nd division is sensory and autonomic
 Enable taste to the anterior 2/3rds of the tongue
 Controls submandibular and sublingual salivary glands, the lacrimal glands (tears) and the soft palpate and around the external auditory meatus
- More likely in people between 20-50 years of age
- Onset results in weakness to flaccid paralysis of facial muscles
 Most distinguishing symptoms is the eye’s inability to close
- Fear due to the symptoms being similar to a stroke—which affects the lowers muscles of the face
- Symptoms depend on lesion site:
 Before geniculate ganglion
 Includes motor, sensory and autonomic
 Includes pain
 Along the pathway from the ganglion to the stylomastoid foramen
 Motor loss and some sensory and autonomic
 After the facial nerve leaves the stylomastoid foramen
 Motor function only
- Recovery depends on the severity of the damage to the nerve
 Compression 2-8 weeks
 Complete lesion poor prognosis
- Facial nerves regenerate irregularly
 Nerve for the eye may innervate the mouth OR nerve for salivation may go to the lacrimal glands (for tears)  called
“crocodile tears”
- No medical treatment givens because 70% recover
 Eyepatch and antibiotics drops may be prescribed to prevent infection
 Steroids in the presence of pain and when prognosis is poor
 24 hours after onset
 Splint may be placed on strained facial muscles (hook in mouth goes to ear)
 Massage is useful for maintaining circulation and tissue health, decreases the sensation of pulling and distortion
- The Cause of Bell’s Palsy
 Not entirely understood
 Compression from edema and swelling
 Pregnancy (85% through 3rd trimester, resolve postpartum), ear infection, diabetes, hypertension,
hypothyroidism, leprosy or tumor
 Even minor swelling could cause compression/lesion
 Conditions affecting the parotid gland
 Inflammation due to mumps or cancer
 Compression from inflammation secondary to trauma
 Blow or stab wound to the side of the head and neck
 Forceps during delivery or child laying on hard object or bony surface
 Mastoid process is not present at birth
 Exposure to a chill or draft
 Experienced by whiling or from an open window while sleeping
- Symptoms
 Rapid onset of unilateral weakness follow by flaccid paralysis of the facial muscles
 Inability to raise eyebrows; forehead cannot wrinkle horizontally of medially
 Incomplete closure of the eye
 Loss of the blinking reflex
 Inability to actively flare the nostrils
 Inability to raise corners of the mouth = whistle or pucker
 Difficult eating
 Difficulty articulating sounds
 Difficult holding the lower lip to a glass/preventing dribbling
 Sensory and Autonomic
 Loss of control of lacrimation (tear production) and salivation
 Loss of taste to the anterior 2/3rds of the tongue
 May be an unpleasant taste
 Heightened sensitivity of hearing
 Low tones AKA hyperacusis
 Distortion of sound
 Sagging of the face and eyelids
 Pulling toward the unaffected side of face
 Folds around the eye, nose and mouth disappear and takes on a smooth appearance (mask appearance)
 Facial expressions are distorted
 Pulling toward the unaffected side of face
 A grimace like expression
 Often embarrassment and anxiety about recovery and reason
 Pain
 Not usually
 But a predictor to poor prognosis
 Opposing Facial muscles
 Feel tense
 Sensation of pulling
 A slow functional return
 Contracture formation
- Contraindications
 Avoid eye due to increased chance of eye infection, especially if tearing is diminished
 Pressure modified due to flaccid tissue
 No long dragging stroke and fascial techniques on affected side
- Assessments
 Observation
 Pulling of the face downward on affected side
 Eye, mouth drooping
 Affected side appears smooth at the creases of the mouth, nose and forehead
 Unaffected side pulls
 Facial expressions are distorted
 Head may be facing down and away to hide sometime hand is used to cover face
 Tears may be seen
 Possible eyepatch or splint
 Palpation
 USE LIGHT TOUCH especially on frontal bone
 Flaccidity over forehead, eye, nose and mouth and platysmas, stylohyoid and posterior belly of digastric muscles
 Edema if condition is systemic or due to local trauma
 Range of Motion
 AROM
 Testing facial muscles and eyes
 ISO
 Orbicularis oculi muscle
 Special Tests
 Dermatome
 V1 = Ophthalmic (op-thal-mic)
 V2 = Maxillary
 V3 = Mandibular
 Myotome
 Vertebral Artery Test (R/O)
 Chvostek Test  mandatory
- Treatment Goals
 Positioning
 Supine
 Contraindication for prone
 Head in mid-line
 Support affected side when treating opposite side
 Folded towel for pressure OR modified minimal pressure on affected side
 Another towel or tissues for tears
 Eyepatch may be removed with permission
 Hydrotherapy
 Cool wash cloth on affected side
 Effective for edema
 Local heat for shortened muscles and TP for unaffected side
 Slow soothing techniques with minimal pressure towards center of face
 Stroking, effleurage, petrissage (fingertip kneading)
 Stimulate
 Vibrations, stroking and compressions
 Unaffected side first
 This decreases tone and relaxes the antagonist muscles and the pulling effect
 Treat compensatory changes and holding patterns
 Decrease hypertonicity
 Decrease TP in the neck and shoulder
 Reduce edema
 Prevent contractures
 Encourage motor re-education and maintain client awareness of affected tissues and range of motion
 Through PROM facial muscles, jaw and cervical
- Self-care Goals
 Recommend self-massage
 Improve functional ability
 Passive and Active Assisted ROM
 Acute
 Shorter more frequent treatments
 30 minutes 2-3 times per week
 Later reduced to once a week
Complex Regional Pain Syndrome
Complex regional pain syndrome

Definition Signs and Symptoms 3. Stage III, Atrophic Stage
- Collection of signs and symptoms - 3 major issues:  Irreversible changes to bones, joint, muscles
 Long-lasting pain  Burning pain  May spread proximally to other areas
 Changes to tissues in the area  At the site and in the areas  Pain is typically unresponsive to treatment
- Used to be called  Autonomic dysfunction Treatment
 Reflex sympathetic dystrophy  Changes in skin temperature and texture, edema, - Best if instituted early, hard to identify early
 Causalgia hair and nail growth - Physical, occupation, recreational therapy, hydrotherapy
- Progressive, potentially debilitating  Changes in circulation - TENS units, topical analgesics, biofeedback
Demographics  Possible loss of bone density - Psychotherapy
- 1-2% of those with fractures?  Motor dysfunction - Chemical nerve block
- 2-5% of those with peripheral nerve injury?  Weakness, spasm in local muscles - Intrathecal pump
- Women seem to be more vulnerable than men  Joint stiffness that may progress to atrophy - Sympathectomy
Etiology - Hyperalgesia - Medications
- With a threatening or painful stimulus, the sympathetic nervous  Excessive pain sensation Medications
system reacts - Allodynia - NSAIDs for early-stage CRPS
- An initial trauma (usually to hand or foot)  Pain reaction to any sensory signal - Oral analgesics
- Often associated with gunshots or shrapnel - 3 stages - Antidepressants
 Also seen with minor sprains, other minor injuries 1. Stage I, Acute Stage: - Anti-seizure medications
 Post-stroke, post-surgery… unpredictable  Injury – 3 months Massage Therapy Implications
- Pain causes a sympathetic response, an exaggerated  Severe burning pain at the site of injury Risks: Painful touch is contraindicated; be aware of any other
inflammatory response reinforces the pain… positive feedback  Muscle spasm treatments the client may be using – especially narcotic painkillers
loop and self-sustaining pain  Reduced range of motion Benefits: If massage can be offered in a way that doesn’t make pain
- Pain sensors becomes increasingly sensitive  Hair and nail growth worse, it could add to quality of life in a very challenging situation
 At the site  Red, swollen, sweaty skin Research: Lymphatic works shows some benefits ins mall studies.
 In the CNS 2. Stage II, Dystrophic stage Some doctors recommend self-massage to help institute healthy
 Receptive field (painful area) expands  3-6 months after injury sensation.
- Physiological changes accrue:  Swelling spreads proximally
 Circulation affects the skin  Skin turns bluish, hair and nails stop growing
 Bones are thin  Intensely painful
 Joints may fuse  Muscles, bones, joints begin to atrophy
Spinal Cord Injury
Spinal cord injury

- Damage to nerve tissue in the spinal canal - Respiratory infection
- 5 categories: - Deep vein thrombosis, pulmonary embolism
 Concussion - Urinary tract infection
 Tissue is jarred not structurally damaged - Decubitus ulcers
 Contusion - Heterotopic ossification
 Bleeding in the spinal cord - Autonomic dysreflexia
 Compression - Cardiovascular disease
 A damages disc, bone spur or tumor puts pressure on the spinal cord - Numbness
 Laceration - Pain
 The cord is partially cut - Spasticity, contractures
 Transection Signs and Symptoms
 The cord is severed completely - Depends on what part, how much the spinal cord is affected
- Injury to lower half of the body is paraplegia  Anterior cord injuries: loss of motor function
- Injury from the neck down is tetraplegia or quadriplegia  Posterior cord injuries: loss of most sensation
Demographics  Lateral cord injuries: pain, temperature sensation
- 12,000 new spinal cord injuries/year - Most injuries affect multiple areas
- 275,000 people liv with spinal cord injuries Treatment
- Men > women, 4:1 - Emergency surgery to remove pressure if possible
- Main causes: - Limit secondary damage as quickly as possible
 Motor vehicle accidents 37% - Implanted electrodes, transplanted tendons may enable movement
 Falls 29% - Physical therapy to benefit cardiovascular system, improve reflexes
 Violence 14% Medications
 Sports 9% - For new injuries:
 Unknown or unreported 11%  Steroidal anti-inflammatories
 Alcohol is a factor in 25% of all spinal cord injuries  anticoagulants
Etiology - For long-term patients:
- Usually a crushing blow, can be a penetrating injury  Anticoagulants
- First event is spinal cord shock:  Antihypertensives for autonomic dysreflexia
 Cord swells, all body function is impaired, muscles are hypotonic  Antibiotics as needed
- When inflammation subsides…  Muscle relaxants
 Muscles tighten  Botox injections
 Reflexes become hyperactive  NSAIDs, opioids, anti-seizure medications for pain
 Spasticity develops  Antidepressants
 Autonomic dysreflexia Massage Therapy Implications
- Flaccid muscles reflect peripheral nerve damage (lower motor neurons) Risks: Check the list of complications, and work within the limitations of the client. Be especially careful
- Spasticity reflects CNS nerve damage (upper motor neurons) of pain, numbness, and the risk of DVT
- Ultimate function depends on how much tissue damage accrues; posttraumatic reactions can make Benefits: Non-task-related touch is a rare gift for spinal cord injury patients. Massage therapy is a
things worse: popular intervention for this group, and may help greatly with pain.
 Excessive bleeding in, around cord Options: Work for pain relief, and also for proprioceptive function and muscle tone within functioning
 Free radical activity areas; this may slow the progress of lost function due to proprioceptive messages.
 Secretion of excess glutamate and excitotoxicity Research: Massage have been seen to be especially useful for pain and bowel function for spinal cord
 Immune system activity leading to inflammation and scar tissue injury patients.
 Accelerated apoptosis
 Scarring that prevents axons from reconnecting
Stroke
- Homan’s sign – DVT
- Never hold patients at the weaker limbs due to dislocation/laxity
- Weight-bearing exercise to the effected side
- Massage Therapy  stroke
Stroke
Definition Risk Factors that Can Be Controlled Hemorrhagic Stroke
- AKA “brain attack”, cerebrovascular accident - Hypertension - Intracerebral hemorrhage
- Damage to brain cells due to oxygen deprivation from… - Smoking  Bleeding deep inside the brain
 Thrombosis - Atherosclerosis - Subarachnoid hemorrhage
 Embolism - C-reaction protein  Bleeding on the surface of the brain
 Hemorrhage - Atrial fibrillation Signs and Symptoms
- Most common type of CNS disorder - High alcohol consumption - A stroke in progress:
Demographics - Drug use  Sudden onset of unilateral weakness, numbness,
- #4 cause of death in US, #1 cause of adult disability - Obesity, sedentary lifestyle paralysis
- Men > women, but women are more likely to die - Diabetes  Blurred, decreased vision, asymmetrical dilation of
- 795,000 strokes/year in US - High-estrogen birth control pills pupils
 610,000 = 1st stroke - Hormone replacement therapy  Difficulty with speaking, understanding words
 185,000 = repeat episode - Depression  Dizziness, clumsiness, vertigo
 160,000 deaths each year - Overall stress  “Thunderclap” headache
 5 million stroke survivors are alive - Sickle cell disease  Loss of consciousness
- World-wide - Obstructive sleep apnea - FAST
 15 million strokes/year Types of Stroke  Face: is one side drooping?
 5 million deaths - Ischemic stroke: from blockage that travels from elsewhere, or  Arms: is one much weaker?
 5 million disabilities forms onsite  Speech: can the person repeat a phrase clearly?
Etiology  Embolism  Time: call EMS is any of these are positive
- Oxygen deprivation kills brain cells  Transient ischemic attack Treatment
 Leading to loss of function elsewhere  Cryptogenic stroke - Prevention, acute care, long-term care
- Oxygen shortage can be from blockage or from bleeding  Cerebral thrombosis (large or small vessel) - Prevention:
- Damage is determined by  Stenosis  Identify people with high risk, encourage preventive
 Location - Hemorrhagic stroke: from bleeding related to aneurysm, measures
 Number of neurons affected hypertension, head trauma, or other factors  Exercise, diet, antiplatelet medications, surgery to
 Amount of secondary damage due to inflammation  Intracerebral hemorrhage correct aneurysm
(ischemic penumbra)  Subarachnoid hemorrhage - Acute care:
- Motor damage: Ischemic Stroke from Embolism  Ischemic stroke: thrombolytics, anticoagulants
 Partial or full paralysis: hemiparesis, hemiplegia - Any clot that travels from elsewhere  Hemorrhagic stroke: relieve pressure in the brain
 On opposite side from the brain lesion - Transient ischemic attack - Long-term care:
 Dysarthria (slurred speech)  “Ministroke”: blockage from a small clot that melts  Physical and occupational therapy, strengthen
- Sensory damage: within hours weakened side
 Permanent numbness  Damage is mild but cumulative Medications
 Vision loss  Warning sign that a large event is imminent - Thrombolytics
- Other damage: - Cryptogenic stroke - Anticoagulants, antiplatelet drugs
 Aphasia  CVA with no known causes - Insulin if blood glucose is high
 Memory loss  Could be related to patent foramen ovale - Antihypertension medications
 Personality changes Ischemic Stroke from Thrombosis Massage Therapy Implications
 Depression - A blockage forms inside a cerebral artery (doesn’t travel from Risks: The risk of other cardiovascular weakness is high for those
Risk Factors that Cannot Be Controlled elsewhere) who have had a stroke, and their medications may require some
- Age  Can affect large of small vessels adjustments in massage therapy choices.
- Gender - Stenosis Benefits: Lost function is largely related to proprioceptive feedback
- Migraines  Same process as atherosclerosis that becomes distorted; massage therapy and other rehabilitative
- Race  Brain damage occurs when the artery is blocked therapies can help to address this. Massage therapy may also help
- Family history with pain and depression.
- Previous stroke Research: Many stroke patients seek massage therapy, which may
be helpful for many aspects of long-term care.
Traumatic Brain Injury
Traumatic brain injury

Definition Contusion Signs and Symptoms: Long-Term Consequences
- Insult to brain tissue - Bruising inside the cranium - Mild to severe cognitive problems, especially memory and
 NOT from congenital or degenerative problems - At the point of impact and at the opposite wall: coup-contre learning
- Leads to coup injury - Movement disorders, seizures
 Altered state of consciousness Diffuse Axonal Injury - Behavior, personality changes
 Cognitive impairment - Internal tearing, shearing or nerve tissue - With repeated injuries: chronic traumatic encephalopathy
 Disruption of physical, emotional, behavioral function  Whiplash - With brainstem injuries: stupor, coma, persistent vegetative
Demographics  Shaken baby syndrome state, etc.
- #1 cause of death, disability for people age 1-44 in US Secondary Injures Treatment
- 1.4 million cases/year Anoxic brain injury: - Surgery to remove pressure if necessary
- 52,000 deaths/year  Complete lack of oxygen: airway obstruction or apnea - Intense physical, recreational, occupational, speech therapy
- About 5 million people now live with TBI Hypoxic brain injury: - Children have the best prognosis
- Leading causes  Not enough oxygen, seen with stroke, carbon - Prevention:
 Motor vehicle accidents, falls, assaults monoxide poisoning, etc.  Many TBIs are transport injuries – wear a seatbelt,
 Fort veterans: exposure to blasts Hemorrhage: wear a helmet!
 300,000 service membranes have had at least 1 TBI  Bleeding inside the brain, rupture aneurysm Medications
Etiology Hematoma: - Anti-seizure medications
- When brain tissue is injured it goes through inflammation  Coagulated leaked blood within or on the surface of the - Antidepressants
response brain - Antipsychotics
 Cranium contains pressure Intracranial pressure: - NSAIDs
 Any swelling damages neurons,  Secondary inflammatory response can follow any type - Muscle relaxants
 More swelling = more damage, etc. of injury - Cholinesterase inhibitors
Types of Traumatic Brain Injury Signs and Symptoms Massage Therapy Implications
Skull Fracture - Vary according to severity and areas affected Risks: Best to work as part of a health care team to integrate with
- Bones of the skull are broken  Frontal lobes: speech, motor dysfunction other therapies. Numbness or communication difficulties call for
- Usually a direct blow  Brain stem: loss of autonomic dysfunction special sensitivity from the therapist.
- Open wounds are less dangerous than closed wounds Signs and Symptoms: Acute Injury Benefits: Massage therapy can be a good part of rehabilitation and
 Risk for intracranial pressure is less - Symptoms may accrue over hours or days maintenance.
Penetrating Injury  Leakage of cerebrospinal fluid from ears or nose Options: Focus on pain and proprioceptive function to maintain
- Usually from a gunshot wound  Visual disturbance, asymmetrical pupils strength and flexibility as much as possible.
- Can be knife or other object  Dizziness, confusion, lethargy Research: Massage therapy is frequently used by TBI patients, and
- Leading cause of death among TBI patients  Nausea, vomiting recommended as part of rehabilitation for returning soldiers.
Concussion  Slow pulse, low blood pressure
- Temporary loss of brain function  In infants: chronic crying, lethargy, change in sleeping
- Most common type of TBI  Loss of consciousness
- A blow, followed by damage at the other side of the brain
- Risk for post-concussion syndrome, especially in athletes
Trigeminal Neuralgia
Trigeminal neuralgia
- Nerve pain at one or more branches of CN V - Sharp, electrical stabbing, burning sensations
- AKA tic douloureux (painful spasm, unhappy twitch)  10 seconds – 2 minutes
Demographics  Muscle tic or grimace
- Diagnosed about 4,000/year in the US - Triggered by
- Affects about 15,000  Speaking, chewing, a draft, touch, nothing…
- Usually in people over 50 years old - Sometimes goes into remission
- Women > men, 2:1 - Sometime progressively gets worse
Etiology Treatment
- Trigeminal nerve is irritated, resulting in episodes of sharp, - Starts with medication, which usually doesn’t work
electrical, burning, stabbing pain on one side of the face - Controlled destruction of the trigeminal nerve
- Can be primary, or secondary to another condition - Microvascular surgery to remove strangulating blood vessel
 Accidents, injuries, tumors, infection, etc. Medications
- Most typical version: blood vessel wraps around the trigeminal - Anti-seizure medications
nerve as it emerges from the pons - Muscle relaxants
 Wears away the myelin - Tricyclic antidepressants
 Allows neurons to misfire - Botox injections
- Autopsies don’t consistently validate this – may be Massage Therapy Implications
multifactorial Risks: Do not elicit symptoms – don’t touch the face without client guidance. A face cradle may also be a trigger; it may be necessary to
work supine.
Benefits: Massage therapy may be able to address secondary muscle holding that goes with this chronic and acutely painful condition,
especially in the neck and shoulders
Trigeminal (V) Nerve - The trigeminal (V) nerve is a mixed nerve - Trigeminal Neuralgia or tic douloureux
- Largest of the cranial nerves  Neuralgia (pain) caused by conditions such as
- Emerges from 2 roots on the anterolateral surface of the pons inflammation or lesions
- Sensory root has a swelling called the trigeminal (semilunar) ganglion located in a fossa on the inner  A sharp cutting or tearing pain lasts secs-mins caused
surface of the petrous portion of the temporal bone by anything that presses on the trigeminal nerve or its
 Contains cell bodies of most of the primary sensory neurons branches
- Smaller root originates in a nucleus in the pons  Occurs exclusively in people 60+ and can be the first
- Has 3 branches: sign of a disease (multiple sclerosis or diabetes) or lack
1. Ophthalmic nerve of vitamin B12 (which damages the nerve)
 Smallest  Injury of the mandibular nerve may cause paralysis of
 Passes into the orbit via the superior orbital fissure the muscles of mastication and loss of sensations of
 Sensory axons from the skin over the upper eyelid, cornea, lacrimal glands, upper part of the touch, temperature, and proprioception in the lower
nasal cavity, side of the nose, forehead, and anterior half of the scalp part of the face.
2. Maxillary nerve
 Intermediate size
 Passes through the foramen rotundum
 Sensory axons from the mucosa of the nose, palate, part of the pharynx, upper teeth, upper lip,
and lower eyelid
3. Mandibular nerve
 Largest
 Passes through the foramen ovale
 Sensory axons from the anterior 2/3rds of the tongue (NOT taste), cheek and mucosa deep to
it, lower teeth, skin over the mandible and side of the head anterior to the ear, and mucosa of
the floor of the mouth
 Brachial motor neurons supply muscles of mastication (masseter, temporalis, medial pterygoid,
lateral pterygoid, anterior belly of digastric, and mylohyoid muscles, as well as the tensor veli
palatini in the soft palate and tensor tympani in the middle ear
 Control chewing movements
 The sensory axons from the branches enter the trigeminal ganglion and terminate in nuclei in the
pons
- Sensory axons conducts nerve impulses for touch, pain, and thermal sensations
- Contain sensory axons from proprioceptors located in the muscles of mastication and extrinsic muscles
of the eyeball
 But these cell bodies are located in the mesencephalic nucleus
Crush and Severance Injuries to Spinal Cord

- Take vitals
- Dermatomes and myotomes
- Cognitive ability
- Fine motor skill testing
- Be gentle, no rhythmically stuff
- Peripheral nerves have the ability to regenerate if the axon is damage, providing the cell body is intact
- If the lesion is too near the cell body or it’s destroyed, regeneration is not possible
 Leads to functional loss distal to lesion site
 AKA Wallerian degeneration will occur over several days
- In crush or chronic compression injuries (axonotmesis), the endoneurial tube is intact, scar tissue will develop at injury site
 Prognosis good, possible regeneration
 Typically regenerates in 10 days
- Severance (neurotmesis)
 5th degree nerve injury according to Sunderland
- Factors that affect regeneration:
 Size of the gap
 Speed of axonal regeneration
 Amount of scar tissue
 Presence of a neuroma
- Doctors may suture the proximal and distal ends
 Often a sural nerve in the lower leg is used to bridge the gap
 If failure another attempt is made in 6 months
- Regeneration of a nerve occurs at a rate of approximately 1-2 millimeters per day
 7-4 mm per week = ½ to ¾ inches per week
 28-52 mm per month = 1 ¼ or 2 ¼ inches per month
 Regeneration is slower the more distal the axon is to the cell body
 Hands or knees, 18-day delay
 Another 5 days before reflexes are functional
 Mixed nerves has a lower rate of success
 But ultimately a successful regeneration will be judged by the return of function and sensation for a client
- Causalgia and reflex sympathetic dystrophy (RS) are severe pain syndromes often associated with traumatic peripheral nerve injuries
 Causalgia affects median and sciatic nerve (tibial division)
- Mainly single nerve lesions are: median, ulnar, radial, tibial or common peroneal nerve
- Combination Lesions
 The more proximal the greater effect on peripheral nerves
 Klumpke’s paralysis is a traction injury of the lower brachial plexus
 Results in median and ulnar nerve lesions
 Poor positioning at birth—breech or legs first—or being pulled by forceps
 Fallings from height and grabbing something to break the fall
 Claw hand presentation combined with thumb positioned on the same plane as the palm
 Atrophy and functional losses of the muscles of the hand
 Severe edema and vasomotor and trophic changes
 Sensory losses affect C8 to T1 dermatomes
 Horner’s syndrome additional complication
 Constriction of the pupil (miosis), drooping of the eyelid (ptosis), loss of sweating to the face and neck (anhidrosis) and recession of the eyeball (enophthalmos)
 Erb’s paralysis
 Upper brachial plexus
 C5-C6
 Includes sensory loss
 Cause:
 Children: Birth trauma when pulled neck extended, rotated and laterally flexed
 Adults: trauma that separates the neck and shoulder  MVA or motorcycle accidents or sports
 Results in: waiter’s tip  hand adducted and internally rotated with elbow extended, forearm pronated and wrist and fingers flexed
 Muscle and motor dysfunction above the elbow, especially shoulder abductors, external rotators and extensors, and forearm supinators and pronators
- Symptoms
 Traumatic injuries damage other structures
 Skin, bone, muscles and tendons
 Scar tissue is present in both complete or partial nerve lesions
 May interfere with regeneration
 Complete lesion
 Edema
 Initially due to injury
 Will remain if autonomic fibers are affected even if regeneration
 More fiber more severe edema
 Altered tissue health
 Autonomic function will affect skin, hair and nails
 Possibly piloerection and loss of sweating
 Tissue will be fragile, dystrophic and easily injured
 Longer healing time
 Motor function
 Flaccid paralysis and muscle wasting within 3 weeks
 Testing will reveal diminished or lost tendon reflexes
 Holding patterns
 Wrist drop (radial nerve) or drop foot (sciatic nerve)
 Contractures
 Flaccid muscles are unable to stop antagonist muscles from contracting resulting in shortened positions
 Occurs more often in a prolonged period of time
 Pain
 Anesthesia of the cutaneous division of the nerve
 May be decreased or altered sensation that the client may interpret as painful
 Partial lesions  although prognosis is better months of probability will cause fear and frustration
 Edema
 Initially due to injury
 Less over time because muscle function assists lymphatic return
 Altered tissue health
 not as severe as complete lesion
 increased piloerectors response may occur
 Motor function
 Variable symptoms depending on damage
 Weakness in some muscles and diminished tendon reflexes
 Less apparent for some muscle function remains
 Ex. finger drop instead of wrist drop
 Contractures
 May develop in the unopposed antagonist
 Are less severe than complete lesion for some muscle function remains
 Pain
 Less likely to have hyperesthesia and dysthesia
 Causalgia and RSD may be present
- Permanent Lesions
 If regeneration does not occur, muscle, sensory and autonomic losses or dysfunction will remain
 Disfigurement may be noticeable
 Edema
 More profound with complete lesions than partial
 Trophic changes and muscle wasting
 Over time tissue is thin and fragile
 Subsequent injury more probably
 Holding patterns will remain
 More pronounced in complete
 Splints are often used
 Scar tissue
 Neuroma may develop
 Found proximal to lesion site
 Often in complete lesions as an attempt to regenerate
 Pain
 Especially with partial lesions
 Areas of anesthesia, hypoesthesia or paresthesia may be present
 Compensatory changes
 Other muscles are used to perform for lost or weak actions
 Tendinitis may occur
- Assessments
 Observations
 Functional losses might be apparent
 Decrease in muscle bulk  measured throughout to see regeneration
 Edema
 Trophic changes of the skin, hair and nails
 Thickening of the skin under the nail
 Crossed ridges or whitish tone on the nail
 Skin lines become less prominent in the fingers, palms and sole of the feet
 Smooth glossy appearance
 Over time dry, scaly and coarse skin and pitted nails
 Initial decrease in hair growth
 Over time excessive hair growth
 Loss of local sweating
 Inflammation or bruising may be present in acute and subacute stages
 Scar is surgery was performed
 Support splints or braces, casts
 Palpation
 CAUTION fragility, disrupting healing process, and altered sensation
 Muscle bulk is reduced
 Complete more apparent, flaccid and lacking resistance
 Edema will feel boggy
 Contractures
 Scar tissue and neuroma may be present
 Neuroma or a pain syndrome will present distal to the site
 Tenderness or painful
 Sensory changes
 Pins and needles; prickly
 Temperature may be different
 Tissue may feel cold due to loss of vasomotor function and tissue dystrophy or atrophy
 Gait
 Sciatic lesion – foot drop
 Posture
 Antalgic facial expression
 Pain syndrome
 Range of Motion
 CONTRAINDICATION!!!
 Actions of traction are avoided (lengthening) until past regeneration
 Protective reflexes may be diminished or lost regardless of stage
 Minimal resistance only!
 AROM
 Movements that can be done easily
 Partial lesion will result in difficult due to muscle weakness
 Complete lesion will result in loss of function of those muscles
 Dual innervation or synergist muscles may present with difficulty
 PROM
 Performed on unopposed antagonist muscles only!
 Assess contractures
 Assess for muscle spasm end feel or leathery end feel
 ISO
 To discern specific lost or weakened function and regeneration
 Minimal resistance only!!!
 Special Tests
 Sensory testing
 Peripheral nerve lesions have a very distinct area of sensory impairment that can be mapped with sharp or reflex hammer
 Peripheral nerve lesions present with hyperesthesia and pain (Causalgia or RSD)
 Complete nerve lesion will present in anesthesia or hypoesthesia
 Dermatomes
 2-point discrimination
 Proprioception
 Piloerector response
 Tinel’s sign
 Deep Tendon Reflex
 Upper Limb Tension Test
 Straight Leg Raise
- Contraindications
 Massage and movement of the affected limb are contraindicated for up to 3 weeks if surgical intervention has occurred
 Massage on site of lesion unless neurologist traces contraction present
 Do not traction (lengthen) or excessively move the limbs until after regeneration process
 Hydrotherapy to the limb should not begin until autonomic and vasomotor control have return
 Initial application should avoid extremes of temperature
 Frictions and deep pressure on the flaccid or compromised tissue
 Caution on flaccid or compromised tissue, especially while grasping the limb or doing PROM
 Joint play is not performed on affect limb until regeneration process
 Introduce with caution
 Rhythmic techniques are avoided anywhere on the body until control has returned, after the regeneration process
 Introduce with caution
- Treatment Goals
 Acute and Subacute Regeneration Lesions
 Work proximally
 Distally will light stroking and minimal pressure of all techniques
 Antagonist muscles: fascial techniques on antagonist muscles are done laterally with moderate pressure OR up until the healthy tissue NOT the flaccid tissue
 No traction (lengthening)
 May shorten with caution
 Positioning
 Supine or seated with upper limb
 Prone or side-lying for lower limb lesions
 Except for sciatic, supine is the best
 Splints or brace, neurologist permission to remove
 Gently move out of holding pattern and placed in neural position
 Pillow elevation for comfort
 Also used when edema is present
 Limb may be secured if other places of the body are worked on with sheet or towel by tucking it under a secured place
 Hydrotherapy
Cool compress for acute stages of healing
 Reduces inflammation and edema
 Modified temperature on fragile or dystrophic tissue
 Contraindicated if altered sensation or vasomotor or autonomics dysfunction
 Proceed cautiously if regeneration progresses with mild temperatures and shortened times
 Decrease pain  Decrease sympathetic nervous system firing
 Provide emotional support
 Address compensatory changes
 Decrease edema
 Decrease hypertonicity
 Decrease TPs
 Promote health of denervated tissues
 Prevent contractures of antagonist muscles
 Maintain health in all joints of the affected limb
 Encourage motor re-education of the affected muscle
 Maintain strength of weak muscles
 Later Stages of Healing of a Regenerating Nerve as Function Returns
 Neurological will advise on motor, autonomic and sensory return
 Techniques are applied proximal to lesion site
 Distal to lesion site of newly innervate tissue with caution
 Gradually increase pressure over series of treatments
 Fascial techniques to unopposed antagonist are useful
 Positioning
 Same as above ^^^
 Until strength has returned do not place in normal resting position or let the limbs hand (arms)
 Hydrotherapy
 Mild contrast washes where autonomic function has returned
 Temperature and time increase with regeneration
 Pressure can also increase (hydrocollators or thermophores)
 Address compensatory changes
 Reduce edema if still present
 Promote tissue health of newly innervated tissue
 Reduce scar tissue formation in the tissue surrounding the lesion site
 Maintain and improve joint health and range of motion
 PROM to mid or full ranges
 Encourage re-education of the affected muscles
 Perform sensory awareness re-education
 Permanent Lesions
 Neurologist will inform of no hope of regeneration
 Now can perform traction (stretching)
 However, rather about dystrophic tissue and compensatory changed
 Techniques applied proximally to lesions and rest of body
 Hypertonicity and TPs are addressed
 Modified pressure to lost or altered sensation, muscle wasting and dystrophic tissue
 Positioning
 Make sure limb is secure or not hanging or susceptible to bumping
 Hydrotherapy
 If permanent loss of autonomic function modification must be maintained
 Weight, temperature and time
 Extra if sensory changes and dystrophic tissue
 Provide emotional support
 Treat compensatory changes
 Decrease edema
 Maintain tissue health, joint and range of motion
 By effleurage and petrissage techniques
 Modified pressure to lost or altered sensation, muscle wasting and dystrophic tissue
 Limit contractures of the unopposed antagonist muscles
 Relaxed PROM and segmental fascial techniques on the unopposed antagonist
 Reduce scar tissue formation at lesion site
 Modified time and pressure
 Neuroma are contraindicated for local frictions
 Maintain awareness of the affected limb
- Self-care Goals
 Acute and Subacute Regenerating Lesions
 Encourage relaxation
 Educate client about tissue health
 When wearing a splint C is vigilant for redness and skin irritation at pressure points
 Encourage motor re-education
 PNF for pain reduction
 Maintain strength and range of motion
 Passive or active assisted movement
 After 3 months ISO exercises
 Encourage ADLs
 Later Stages of Healing of a Regenerating Lesion
 Educate the client
 Encourage motor re-education
 Maintain then increase strength and range of motion
 Encourage re-education of sensory awareness
 Cotton ball, wash cloth, etc.
 Permanent Nerve Lesions
 Encourage relaxation
 Educate the client
 Self-massage
 Maintain strength and range of motion of the affected limb
 Stretching for antagonist muscles
 Encourage ADLs
 30 minutes for initial treatments a few times a week
 45 minutes if relaxation is a priority
 Decreased to weekly during regeneration
 Age, general health of C can be a factor
Handouts – Common Upper and Lower Limb Nerve Injuries
Nerve Common Injuries Deformity

Axillary Nerve Fracture of surgical neck of humerus Wasting of deltoid muscle, making the bones of the should joint very prominent and obvious
Stab wounds to posterior shoulder Should may appear adducted and internally rotated
Anterior should dislocation
Pressure of crutches on armpits (“crutch palsy”)
Musculocutaneous Nerve Musculocutaneous nerve injuries are rare, as the nerve is protected beneath the bulk of the biceps muscle Wasting of anterior compartment of arm
It may be damaged by stab wounds to the upper arm Elbow usually held in extension with forearm pronate
Ulnar Nerve Supracondylar fractures of the humerus Wasting of the hypothenar eminence and intrinsic muscles of hand “Claw Hand” deformity at rest and on
Fractures or soft tissue injuries to medial epicondyle of humerus attempted finger extension—the patient cannot extend the IP jts of their ring or little fingers, resulting in
Stab wounds to forearm or wrist fixed flexion of the IP jts and hyperextension of the MCP jts of these 2 fingers. The clawed appearance is
Blood tests most pronounced when the nerve is injured at the wrist, for ex. by compression in Guyon’s canal, as the
Compression either at the cubital tunnel in the elbow OR at Guyon’s canal in the wrist function of flexor digitorum profundus will be preserved. A claw hand affecting all four fingers is much less
common and is usually due to a lesion of the lower part of the brachial plexus, such as Klumpke’s palsy
Radial Nerve Fractures of proximal humerus, saft of humerus or radius Wasting of triceps and posterior compartment of forearm “Wrist Drop” deformity at rest and on
Stab wounds to antecubital fossa, forearm or wrist attempted wrist extension—the patient cannot extend their wrist/fingers, resulting in unopposed wrist
Blood tests flexion. In the classical description of a radial nerve injury, the forearm is also pronated, the fingers are
Pressure of crutches on armpits (“crutch palsy”) flexed and the thumb adducted.
The patient falling asleep with arm hanging over the back of a chair, classically whilst drunk (“Saturday night palsy”)
Somebody else falling asleep with their head lying on the patient’s arm (“honeymoon palsy”)
Excessive tight plaster casts, wristbands or handcuffs
Prolonged tourniquet use on upper arm, for ex. during orthopedic or plastics procedures
Median Nerve Supracondylar fractures of humerus Wasting of anterior compartment of forearm and thenar eminence “Hand of Benediction” deformity on
Stab wounds to antecubital fossa, forearm of wrist attempted finger flexion—the patient cannot flex their index or middle fingers, resulting in unopposed
Blood tests extension of those two fingers. They cannot make a fist with all of their fingers
Deep wrist lacerations inflicted during deliberate self-harm
Compression by carpal tunnel syndrome
Superior gluteal nerve L4-S1 Latrogenic injury due to intramuscular injections Results in paralysis of gluteus medius and minimus, tensor fascia lata  impair hip abduction.
Positive Trendelenburg sign: lateral pelvic tilt towards the opposite side
Inferior gluteal nerve L5-S2 Posterior hip dislocation Paralysis of gluteus maximus  impaired thigh extension.
Difficulty standing from a sitting position and climbing stairs.
Backward lurching gait (an anormal gait in which the trunk tilts backwards during the heel strike phase in
the limb with the weak hip extensor)
Forward pelvic tilt.
Femoral nerve L2-L4 Direct injury (trauma) Paralysis of iliopsoas, pectineus, rectus femoris, and sartorius muscles  impaired hip flexion
Prolonged pressure on the nerve: psoas hematoma, aortic or iliac aneurysms or tumors Paralysis of quadriceps femoris muscle  impaired knee extension and decreased patellar tendon reflex
Latrogenic: pelvic, abdominal, or spinal surgery Anterior cutaneous branches: anteromedial thigh
Femoral line placement Saphenous nerve lesion: medial lower leg, medial edge of the foot
Lateral femoral cutaneous nerve Compression at the level of the inguinal ligament caused by: Pain and paresthesia on the lateral surface of the anterior thigh
(meralgia paresthetica) Increased intra-abdominal pressure (e.g., pregnancy, obesity, ascites) Can be improved by wearing looser clothing and/or losing weight.
External compression (e.g., tight belts, pants, or compression dressings)
Local compression (e.g., tumors, hematomas)
Obturator nerve Pelvic ring fractures Paralysis of hip adductors
Obturator hernias Medial thigh paresthesia
Sciatic nerve L4-S3 Latrogenic (misplaced intragluteal injection) Paralysis of hamstring muscles  impaired knee flexion
Direct trauma (gun and/or stab wounds) Motor deficits of tibial nerve injury and common peroneal nerve injury
Hip dislocation Paresthesia of lower leg and foot
Total hip arthroplasty
Tibial nerve L4-S3 Tibial fracture Paralysis of foot flexors  inability to walk on the toes or balls of the feet, and inability to invert foot
Tarsal tunnel syndrome Sensory loss over sole of the foot  Morton neuroma
Common Peroneal nerve L4-S2 Fracture of the fibular head Deep peroneal nerve: paralysis of foot and toe extensors (dorsiflexors)  foot drop  high-stepping gait
Compression: tight casts, sitting cross-legged, Lithotomy position during surgery Superficial peroneal nerve: paralysis of peroneus longus and brevis  impaired pronation of foot.
Abnormal sensation between big and 2nd toe for deep peroneal; superficial peroneal lateral surface of the
lower leg, dorsum of the foot and toes, EXCEPT space between big and 2 nd toe
Sural (Tibial) nerve L4-S3 Achilles tendon rupture Abnormal sensation in posterolateral side of the lower leg, the lateral border of the foot and small area
Entrapment neuropathy (e.g., crural fascia thickening) under the heel
Ganglion
Lipomas
Handout – Tarsal Tunnel Syndrome
- Tarsal tunnel syndrome is pain along the course of the posterior tibial nerve, usually resulting from nerve compression within the tarsal tunnel
- At the level of the ankle, the posterior tibial nerve passes through a fibro-osseous canal (flexor retinaculum) and divides into the medial and lateral plantar nerves
- Tarsal tunnel syndromes refers to compression of the nerve within this canal, but the term has been loosely applied to neuralgia of the posterior tibial nerve resulting from any cause
- Synovitis of the flexor tendons of the ankle caused by abnormal foot function, inflammatory arthritis, fibrosis, ganglionic cysts, fracture and ankle venous stasis edema are contributing factors
 Cs with hypothyroidism may develop tarsal tunnel-like symptoms as a result of perineural mucin deposition
- Symptoms and Signs
 Pain (occasionally burning and tingling) is usually retro-malleolar and sometimes in the plantar medial heel and may extend along the plantar surface as far as the toes
 Pain is worse during standing and walking, pain at rest may occur as the disorder progresses
 This help distinguish it from plantar fasciitis
- Treatment
 Foot inversion with braces or orthoses, NSAIDs, corticosteroid injections, surgery, or a combination
 This reduces nerve tension
Wiley – Nerve Lesions
- Injuries to nerves emerging from the Brachial Plexus

 May result from forcefully pulling the head away from the shoulder, a heavy fall on the shoulder, stretching an infant’s neck during childbirth.
 Erb-Duchenne palsy - the arm looks like: shoulder adducted, arm medially rotated, elbow extended, the forearm pronates and the wrist flexed
 There is loss of sensation along the lateral side of the arm
 Injury to the radial (axillary) nerve caused by improper intramuscular injections into the deltoid muscle or when a cast is applied too tightly
 Indicated by wrist drop, the inability to extend the wrist and fingers
 Minimal sensory loss due to multiple innervations
 Injury to the median nerve may result in median nerve palsy, symptoms include numbness, tingling and pain in the palm and fingers
 Inability to pronate the forearm and flex the PIP of ALL digits and DIP of the 2-3 rd digits
 Wrist flexion is weak (and accompanied by adduction) as well as weak thumb movements
 Injury to the ulnar nerve may result in ulnar nerve palsy AKA clawhand which is indicated by the inability to abduct or adduct the fingers, atrophy of the interosseous muscles of the hand, hyperextension of the MCP joints, and flexion of the IP joints
with loss of sensation of the pinky
 Injury to the long thoracic nerve AKA winged scapula results in paralysis of the serratus anterior, the medial border of the scapula protrudes (winging), arm is raised, vertebral border and inferior angle of the scapula pull away from the thoracic wall
protruding outward
 Arm can’t be abducted beyond the horizontal position
 Thoracic outlet syndrome is the compress of one or more nerves in the brachial plexus
 Subclavian artery and vein may also be compressed resulting in spasm of the scalenes or pectoralis minor, presence of a cervical rib (embryological anomaly), or misaligned ribs
 Symptoms: pain, numbness, weakness or tingling in the upper limb across the upper thorax or scapula
 Exaggerated during physical or emotional stress increasing the contraction of muscles involved.
- Injuries to the Lumbar Plexus
 Femoral Nerve
 Occurs in stab or gunshot wounds
 Inability to extend the leg
 Loss of sensation in skin over the anteromedial aspect of thigh
 Obturator nerve
 Results in paralysis of the adductor muscles of the thigh and loss of sensation over medial thigh
 May result from fetal head delivery
Median, Radial & Ulnar Injuries

Radial Injuries
- Radial nerve is a continuation of the posterior C5-T1 of the brachial plexus

- Continues through the long and medial heads of the triceps to the radial groove of the humerus and winds to the anterior arm/radius
- Crosses the elbow joint branches into superficial and deep
 Deep terminates at the wrist
 Superficial divides into more branches
- Radial artery travels on the medial side
- Most common at the lower half or third upper arm is site of lesion
- When proximal to elbow before it branches both sensory and motor effected
- When distal to the elbow only one branch is effected, either or
- Muscles Innervated by the Radial Nerve
 Triceps
 Anconeus
 Brachioradialis
 Extensor carpi radialis longus and brevis
 Supinator
 Extensor digitorum
 Extensor carpi ulnaris
 Extensor digit minimi
 Extensor pollicis longus and brevis
 Abductor pollicis longus
 Extensor indicis
- Causes of Lesions of the radial nerve are:
 Fractures
 Humerus at the radial groove 70%
 Dislocation
 Head of radius either with humerus or ulna
 Post-surgical complication
 Unrelieved pressure from poor positioning during surgery
 Compression
 Primarily at the axilla from crutch use
 “Saturday night palsy” from draping an arm over a hair or table edge
 “honeymoon palsy” from the head resting on the arm
 Or from alcohol or drug use
 Supinator syndrome
 Compression from fibrosis (from overuse) at the site where the nerve penetrates the supinator muscles
 May result in first degree (neuropraxia) or second degree (axonotmesis) nerve lesion
- Symptoms
 Complete radial nerve lesion AKA wrist drop
 Hand hands in flexion because the wrist flexors are unopposed due to the flaccid wrist extensors
 Muscle wasting depending on lesion site
 Triceps, brachioradialis and extensor carpi ulnar
 Dorsum of the forearm between the radius and ulna
 Swelling on the dorsum of the hand
 Altered sensation at the posterior arm, forearm and hand, specifically the thumb, index, middle and half the ring finger (excluding fingertip)
 Anesthesia between the web of the thumb and 2 nd finger
- Motor Dysfunction Due to a Complete Lesion
Lesion Site Functions Affected Muscles Involved
Lost function unless other Innervated by
nerves can perform action Radial nerve Other nerves
Substitute Movement
Axilla Elbow extension Triceps; Anconeus
Upper arm to elbow Elbow flexion in neutral position Brachioradialis Biceps brachii & Brachialis (musculocutaneous nerve)
Elbow to forearm Supination Supinator Biceps brachii (musculocutaneous nerve)
Wrist extension Extensor carpi ulnaris; Extensor carpi radialis longus and brevis; Assists extensor digitorum
Wrist ulnar deviation/adduction Extensor carpi ulnaris Flexor carpi ulnaris (ulnar nerve)
Wrist radial deviation/abduction Extensor carpi radialis longus and brevis; Abductor pollicis longus; Extensor pollicis longus and brevis
MCP extension Extensor digitorum; Extensor indicis; Extensor digiti minimi
IP extension Extensor pollicis longus Abductor pollicis brevis (median nerve)
MCP thumb extension Extensor pollicis longus and brevis; Abductor pollicis longus
CMC thumb abduction Abductor pollicis longus Abductor pollicis brevis (median nerve)
Ulnar Injuries
- Ulnar nerve originates from the medial cord of the brachial plexus (C8-T1)
- Follows the posterior wall of the axilla under the pectoralis minor with the median nerve
until mid-upper arm
- Travels along the medial triceps at the elbow goes posterior to the medial epicondyle of the
humerus and medial to the olecranon process
- Continues to the wrist
- At the wrist it travels over the flexor retinaculum between the pisiform and hook of the
hamate bone beneath the volar carpal ligament AKA Guyon’s canal/ulnar tunnel a site for
compression
- Motor nerve divides into superficial and deep
 Superficial is primarily sensory  supplied the ulnar side of the little finger and ring
finger
 Deep is primarily motor
- 2 main sensory branches: dorsal branch and palmar branch
- Between and deep to the head of the flexor carpi ulnaris muscle is a common site of
lesion/most vulnerable at the superior posterior elbow
- Most common site is where it emerges from under the tendon of the flexor carpi ulnaris at
the pisiform
- Muscle Innervated by the Ulnar Nerve
 Flexor carpi ulnaris
 Flexor digitorum profundus (ulnar or medial half) innervation is shared with the median
nerve
 Hypothenar muscles:
 Abductor digiti minimi
 Flexor digiti minimi
 Opponens digiti minimi
 Third and fourth lumbricals
 Palmar and dorsal interossei
 Adductor pollicis
 Flexor pollicis brevis (deep head) innervation is shared with the median nerve
- Causes of lesions of the Ulnar Nerve are:
 Fractures
 Medial condyle of the elbow, mid-forearm or wrist (also called a Colles’ fracture)
 Dislocation of the elbow
 Post-surgical complications from arm hanging over edge of table while under anesthesia
 Pathology
 Leprosy
 Prolonged compression
 Resting elbow on hard surface
 Wearing a tight wrist band or handcuff
 Bicycling
 Repetitive actions
 Pitching  repeated flexion and extension
 Fibrosing at medial elbow or at Guyon’s canal which can result in first degree (neuropraxia) or second degree (axonotmesis) nerve lesion
 Direct trauma
 Contusion, laceration of the wrist or hand
 Often in combination with median nerve lesion
- Symptoms
 Complete ulnar nerve lesion results in claw hand
 Pinky and ringer finger are hyperextended and abducted at the MCP joint and flexed at the IP join
 Result of loss of finger flexors leading to unopposed extensor pulling of the fingers
 Loss of the third and fourth lumbricals, and interossei
 Loss of adductor digiti minimi results in abduction of the pinky
 Froment’s sign is positive with an ulnar nerve lesion
 Muscle wasting is most remarkable at the hypothenar eminence and in the interosseous spaces
 Altered sensation, anhidrosis (diminished or absent sweating) and vasomotor changes (Allen’s Test)
 Altered sensation on the ulnar side of the hand, especially little finger and half of the ring finger
 Palmar and dorsal aspect
 Just above the head ulna to the digits
 Anesthesia occurs in the little finger to the wrist
- Motor Dysfunction Due To a Complete Lesion
Lost function unless other nerves can perform action Innervated by
Ulnar nerve Other nerves
Substitute Movement
Upper arm to elbow Wrist flexion (complete lesion only weakened) Flexor carpi ulnaris; Ulnar half of flexor digitorum profundus Palmaris longus; flexor digitorum superficialis; radial half of flexor digitorum profundus (median nerve)
and forearm Flexor carpi radialis; abductor pollicis longus (radial nerve… will draw wrist radially)
Wrist adduction (complete lesion only weakened) Flexor carpi ulnaris Extensor carpi ulnaris (radial nerve)
Ring and pinky flexion at DIP Ulnar half of flexor digitorum profundus
Wrist Adduction of the thumb at the MCP joint Adductor pollicis; first palmar interossei assisted by the first dorsal interossei
Note: common for Opposition of the pinky Opponens digiti minimi; 3rd and 4th lumbricals; flexor digiti minimi
muscles with shared Flexion at the MCP joint and extension of the IP joint of 3rd and 4th lumbricals; assisted by 3rd and 4th palmar and dorsal interossei
innervation with the the ring and pinky fingers
median nerve Flexion of the MCP joint of the thumb (complete lesion Flexor pollicis brevis (deep heat) Flexor pollicis brevis (superficial head, median nerve)
only weakened)
Abduction of pinky (complete lesion only weakened) Abductor digit minimi Extensor digit minimi; extensor digitorum (radial nerve)
Abduction of index, middle and ring fingers Dorsal and palmar interossei Extensor digitorum (radial nerve… assists with abduction of the digits)
Adduction of index to pinky (complete lesion only
weakened)
Median Injuries
- Innervates primarily the flexor muscles of the forearm and hand

- Originates from the medial cord (C8-T1) and the lateral cord (C5-7) or the brachial plexus
- Travels with the axillary-brachial artery down the radial aspect of the arm from the axilla to the cubital fossa
- Then runs BETWEEN the pronator teres muscle where it is susceptible to compression
- Before entering the carpal tunnel at the wrist gives off the palmar cutaneous branch supply sensory to the thenar area
- Travels into the carpal tunnel along side flexor pollicis longus, flexor digitorum superficial and digitorum profundus
- Then branches off into the hand
- It is well protected in the forearm from traumatic injury
- Susceptible to compression by the pronator teres, flexor carpi radialis and flexor digitorum superficialis
- Most commonly injured when it’s superficial, at the elbow and wrist
- Muscles Innervated by the Median Nerve
 Pronator teres
 Flexor carpi radialis
 Flexor digitorum superficialis
 Flexor digitorum profundus (radial or lateral half) innervation shared with the ulnar nerve
 Palmaris longus
 Pronator quadratus
 Thenar muscles:
 Abductor pollicis brevis
 Opponens pollicis
 Flexor pollicis brevis
 First and second lumbricals
- Causes of lesions of the median nerve are:
 Fractures
 Elbow, wrist and carpal bones
 Rarely in upper arm
 Dislocations
 Elbow, wrist or carpal bones
 Primarily lunate and scaphoid
 Compressions
 From fibrosing and hypertonicity in overused muscles
 Can result in first degree (neuropraxia) or second degree (axonotmesis) nerve lesion
 Pronator teres syndrome
 Carpal tunnel syndrome
 Trauma
 traction (stretching) injury, contusion or laceration, especially at wrist (self-harm) or hand
- Symptoms
 Complete median nerve lesion AKA ape hand or oath hand deformity
 Ape hand refers to the thumb lying in the same plane as the fingers due to loss of opposition
 Oath hand appears when they try to make a fist
 3rd and 4th digits can only make a fist
 Loss of thenar flexors and opponens pollicis, flexors of the index and middle finger
 Flaccidity with a complete lesion
 Possible medial rotation of thumb
 Difficulty holding a pen or grasping objects
 Because opposition involves both flexion and abduction and internal rotation of the CMP and flexion of the MCP joint of the thumb
 Autonomic loss, results in trophic and vasomotor changes
 Edema in the hand, fingers and thumb
 Nail changes (ridges) and skin changes (skin is thin, glossy, lacking lines)
 Muscle wasting and atrophy of forearm flexors and thenar muscles
 Risk of causalgia
- Sensory dysfunction as a Result of a Lesion
 Altered sensation on the thumb, index, middle and half the ring finger (flexor/palmar surface) and the distal 2/3rds of the palm
 Anesthesia occurs at the DIPs of the index and middle finger
- Motor Dysfunction Due to a Complete Lesion

Lost function unless other nerves can perform action Innervated by
Median nerve Other nerves
Substitute Movement
At or proximal to Pronation Pronator teres; pronator quadratus Brachioradialis (radial nerve… not complete pronation)
the elbow and in Wrist flexion (complete lesion only weakens) Palmaris longus; flexor digitorum superficialis; radial half of flexor digitorum Flexor carpi ulnaris (ulnar nerve)
the forearm profundus; flexor carpi radialis (radial nerve) Ulnar half of flexor digitorum profundus (not complete ulnar deviation); Abductor
pollicis longus (not complete radial deviation)
Wrist abduction Flexor carpi radialis (radial nerve) Extensor carpi radialis; extensor carpi pollicis longus and brevis (not complete extension
and abduction)
Flexion of thumb at Ips Flexor pollicis longus
Flexion of index and middle fingers at DIP joint Radial half of flexor digitorum profundus
Flexion of index to pinky at PIP joints Flexor digitorum superficialis; assisted by flexor digitorum profundus for
index and middle finger
At wrist or hand Abduction of thumb at CMC and MCP joints Abductor pollicis brevis (radial nerve) Abductor pollicis longus; extensor pollicis brevis (assist at CMC)
Note: shared Opposition of thumb Opponens pollicis; assisted by flexor pollicis brevis
innervation with Flexion at MCP and extension of IP of index and middle 1st and 2nd lumbricals
ulnar nerve fingers
Flexion of MCP of thumb Flexor pollicis brevis (superficial head); assisted by flexor pollicis longus Flexor pollicis brevis (deep head) (ulnar nerve)
Nervous System Birth Defects

Spina Bifida
Spina bifida
Definition Types of Spina Bifida Signs and Symptoms
- A neural tube defect: Spina Bifida Occulta - SB occulta may be silent, may have a dimple or tuft of hair at
 The vertebral arch doesn’t close over the spinal cord - The vertebral arch (usually lumbar) doesn’t close the site
- “cleft spine” - No signs or symptoms are obvious - Cystic SB is obvious: a sac protrudes from the back of a
- Occurs in a range of severity - Person may never know or… newborn
Demographics - Person may have serious problems  Usually lumbar or thoracic
- About 166,000 people in the US have spina bifida  Tethered cord, leading to - Nerve function below the repaired cyst is impaired or absent
- Rates are decreasing with better prenatal care  Pes cavus with SB myelomeningocele
Etiology  Bladder, bowel problems Treatment
- Neural tube defects happen between day 14-28 after  Etc. - Surgery to repair cyst, preserve as much spinal cord function as
conception - If problems develop, it’s usually at puberty: growth spurt possible
- Usually related to folate deficiency stretches the spinal cord - May be conducted in utero
- If the neural tube and vertebral arch don’t close, material may Spina Bifida Meningocele - Physical therapy, exercise, education in using assistive devices
protrude to form a cyst on the spine (cystic spina bifida) - Rarest type of cystic spina bifida: - Multiple surgeries for other complications
Complications  Arachnoid and dura mater press through the open Medications
- If the neural tube doesn’t close completely, the baby is at risk vertebral arch - Anticholinergics for bladder function
for…  No nerve tissue - Alpha adrenergic drugs for bladder function
 Meningitis  Easily repaired - Tricyclic antidepressants
 Hydrocephalus  Usually no long-term repercussions Massage Therapy Implications
 Chiari II formation (brain protrudes into spinal canal) Spina Bifida Myelomeningocele Risks: Be aware of numbness and other complications related to
 Learning disabilities - Most common, most severe form of cystic spina bifida nerve damage and paralysis, including decubitus ulcers and
 Extreme allergies - 94% of diagnosed cases scoliosis
 Tethered cord - Spinal cord and/or cauda equina protrude with meninges into a Benefits: If risks are addressed, massage therapy can be helpful and
 Decubitus ulcers large cyst supportive for clients with SB.
 Bowel, bladder problems, urinary tract infections - Often involves several open vertebral arches Research: Massage therapy is a popular choice among parents
 Renal failure - If the skin doesn’t cover the cyst, the risk of infection is high looking for options for their children with spina bifida; for this
 Scoliosis reason it is important to be knowledgeable about this condition.
Cerebral Palsy
Cerebral palsy
Definition Complications Signs and Symptoms
- Collective term for brain injuries that occur during gestation - Pain - Vary by location of brain injury, severity
and early infancy - Seizures - Usually develop between 6 months – toddlerhood
- Types have been delineated according to how brain - Hearing loss - Early signs:
development is affected - Strabismus  Hypertonicity, hypotonicity
Demographics - Digestive problems  Problems with walking
- Stable numbers in the US may reflect better survival of - Urinary incontinence  Weak muscles, random movements
premature babies, who are vulnerable to cerebral palsy - Drooling, risk of cavities  Hearing, vision problems
- Highest incidence among mothers who smoke, live in poverty, - 2/3 have mental disability - In adults:
don’t receive prenatal care, or have had previous preterm - Contractures and musculoskeletal problems  Accelerated aging
babies - In adults: poor stamina, generally low resilience  High incidence of fatigue, exhaustion, overuse
- 764,000 people in US with cerebral palsy now Types of Cerebral Palsy syndromes
Etiology Spastic CP Treatment
- Brain damage, usually to motor centers - Most common form, 60-75% of all cases - Not curable, not reversible
- 3 groups of causes: - In some areas the flexors are tight, extensors give up: - Managed with skill-building and assistive equipment
1. Prenatal causes  “clasp-knife” effect - Occupational, speech, physical therapy
 Maternal illness, infection; hyperthyroidism, diabetes, Athetoid CP - Medication for seizures, spasms
Rh sensitization - Very weak muscles - Surgery for orthopedic problems
 Toxic exposure - Involuntary writhing of extremities, face, mouth - Treatment needs for adults are different than for children
 Abdominal trauma Ataxic CP  New population
 Pregnancy-induce hypertension - Rare version  Not well served yet
2. Birth Trauma - Chronic shaking Medications
 Anoxia or asphyxia during birth - Intention tremor - Oral, injected muscle relaxants for spasticity
 Respiratory distress - Poor balance - Botox
 Head trauma with forceps Dystonic CP - Injected antispasmodic medication
3. Acquired CP - Slow, involuntary twisting of trunk, extremities - Anti-seizure medication
 Jaundice Mixed CP - Bisphosphonates for bone density
 Head trauma - Combination of forms, affects many patients Massage Therapy Implications
 Infection Risks: If verbal communication is not easy, be sensitive to non-
 Hemorrhages verbal signals. Numbness may be present. Be aware of medications
 Neoplasms that may influence treatment options.
Benefits: Massage therapy can be helpful for pain, stress, muscular
efficiency, digestive function, and muscle tone. This is true for
children and adults with CP.
Options: Focus on tone and proprioception for improved efficiency
and preserved movement capacity.
Research: Parents of children with CP are enthusiastic users of
massage therapy. It shows benefits for pain, relaxation, mobility,
and bowel function.
- Cerebral palsy (CP) is a term used for motor function disorders that result from damage to the immature brain
- “cerebral” = brain; “palsy” lack of movement control
- Non-progressive, symptoms change as the child ages and the CNS matures
- Occurs during perinatal period to 3 years of age from brain damage
- Plastic diplegia accounts for 75% of all cases that involves spasticity in the lower limbs and hips as the primarily symptoms
- Affects boys more than girls; 1.5/1
- Manifests in a variety of ways including:
 Monoplegia (one arm or leg)
 Diplegia (usually both legs)
 Triplegia (three limbs)
 Quadriplegia (all found limbs)
 Hemiplegia (one side of the body)
- Causes:
 Stress
 Sensory dysfunction
 Vision and hearing
 Postural dysfunction
 scoliosis and hyperkyphosis which can compromise respiratory and GI function
 compression or nerve entrapment
 early onset arthritis or osteoporosis (also due to medication) fractures
 Structural or functional
 Pain syndromes (acute or chronic)
 Epilepsy
 compromised learning and communication skills, mental developmental delay and emotional disturbances
- Possibly causes of cerebral palsy:
 Hypoxia and ischemia
 In utero
 kink in umbilical cord or wrapping around the fetus’s neck, maldevelopment of the placenta or shock from a trauma the mother
occurs
 Postpartum
 suppression of respiratory center from overmedication of mother before birth, pneumonia, a collapsed lung or drowning of an
infant
 Trauma to, rupture of, cerebral blood vessels
 In utero due to separation of the placenta
 Due to difficult of prolonged delivery (breeched birth or large baby)
 Postpartum
 Head injury from accident or abuse
 Strokes as a result of dehydration
 Toxicity and infection
 In utero
 Rhesus (Rh factor) incompatibility or an infection in the mother from measles, shingles, etc.
 Postpartum
 Meningitis, viral encephalitis and lead and carbon monoxide poisoning
- Four main types of movement disorders:
 Spastic (increased tone)
 Most common
 Athetoid (uncontrolled movement)
 Ataxic (poor coordination)
 Least common
 Mixed (usually spastic and athetoid)
- Medical Treatment for Cerebral Palsy
 No cure
 Physical and occupation therapy
 Speech therapy
 Sports such as swimming or horseback riding
 Surgery to lengthen tendons
 Typically on Achilles tendon to increase dorsiflexion
 Arm flexor tendons in the forearm to increase wrist flexion
 Surgery
 Specific nerve roots are severed (posterior rhizotomy) to reduce spasticity
 Medications to treat spasticity, rigidity and seizures
 Massage therapy address spasticity, temporarily, and secondary conditions
 Can also provide supportive and sensitive touch
- Symptoms
 Impaired movement
 Spasticity
 Most common
 Increases with pain, stress and emotions such as fear or anxiety
 Rigidity possible
 Athetoid
 Slow and writhing movements
 Increase with voluntary movements and stop with sleep
 Choreiform
 Quick, uncontrolled and without purpose movements
 DO NOT stop with sleep
 Ataxia
 Lack of coordination and clumsiness
 In the face causes grimacing
 May be accompanied by intention tremor
 Flaccidity & Reflex movements
 Developmental reflexes are delayed within the first 2 years
 Affected muscles are usually sensitive to stretch
 Pain
 Results from muscular, neurological and bony changes
 Can be long-term postural changes and imbalance
 Generally, perception of pain, temperature and pressure is not affected
 Postural dysfunctions
 Scoliosis  respiratory difficulties due to decrease rib movement and compression of the lung and diaphragm on CONCAVE SIDE
 Hyperlordosis and hyperkyphosis may be present
 Contracture formation
 Reduces range of motion thus function ability
 Equinus deformity caused by a short Achilles tendon which reduces dorsiflexion
 Internal rotation of hip is common with spastic diplegia
 Hip flexion contracture is common
 Epilepsy
 As a result of CNS lesion
 Tissue health
 Disuse leads to atrophy
 Edema
 Risk of decubitus ulcers
 Sensory losses
 Inability to distinguish object through touch (agnosia)
 Decreased proprioception
 Bowel and bladder dysfunction
 Esophagitis, gastritis and ulcers
 Constipation and GI problems can be secondary due to medication, inactivity, postural dysfunction and aging
 Speech
 Dysarthria (impairment in speech pronunciation)
 Speak slowly or it’s difficult to understand
 Inability to swallow or control saliva
 Hearing
 Slight or profound
 Vision
 Normal or limited
 May be cross-eyed or squint
 Blindness possible
 Compromised learning and communication skills, mental developmental delay and emotional disturbances
 Fear, frustration, stress, etc.
 Intellect may or may not be affected
 Increased risk of
 Arthritis
 Lower limbs particular vulnerable
 subluxation, dislocation and cartilage degeneration
 Stenosis (narrowing of the cervical spine)
 Especially with athetoid CP
 Osteoporosis
 Due to non-weight-bearing activity
 Peripheral nerve compressions
 Due to postural imbalances
- Assessments
 Observation
 Spasticity
 Ability to balance and shift weight
 Cane, walker or wheelchair
 Edema often present in distal limbs
 Muscle bulk differences
 Palpation
 Hypertonicity
 Contractures
 Most palpated in wrist flexors, hip flexors and Achilles tendons
 Edema
 Ischemia cool to the touch
 Shoulder, hip and knee pathologies
 Adhesions, inflammation
 Tenderness
 Often due to arthritic changes, peripheral nerve compress or postural changes
 Posture
 Can be performed, noting asymmetries as a result of motor dysfunction, altered biomechanics and the affect limbs and compensation of the unaffected
 Gait
 Circumduction gait
 Range of motion
 May be reluctant due to repeated testing during childhood
 If athetoid movements are present, it’s not useful or accurate
 AROM and PROME
 Decrease range of motion if spasticity is present
 Extreme cases no movement is possible
 ISO
 Not accurate with spasticity or athetoid movements
 Special tests
 Sensory testing
 Dermatome
 Reflexes
 2-point Discrimination
 Proprioception
 Finger to nose
 Heel to shin
 Specific orthopedic tests are performed for secondary conditions
 Tests may not yield viable results in the presence of spasticity or athetoid movements
- Contraindications
 Avoid joint play and aggressive mobilization techniques such as rib springing, especially with osteoporosis or osteoarthritis
 Do not increase sympathetic nervous system firing for it will increase symptoms
 Avoid vigorous or painful techniques
 Modify pressure and hydrotherapy application on areas of altered sensation
 Modify position, techniques and hydrotherapy if hypertension is present
 Decubitus ulcers is a contraindication to local massage
 Early signs: redness, heat, swelling and pain refer out
 Avoid frictions if the client is on anti-inflammatories
 Modify treatment for seizures
- Treatment Goals
 Positioning
 Any if the client is comfortable
 Sleeping position if athetoid movements are present
 Side-lying allows for the best access
 Hydrotherapy
 Be mindful of tissue health, hypertension or other secondary tissue concern
 Individual preference to increase relaxation and decrease muscle tone
 Contrast to improve circulation and tissue health
 Cool application to reduce edema
 Warm or hot for contractures followed by prolonged passive stretching
 Techniques
 Slow, prolonged passive stretching
 DO NOT PERFORM ABRUPTLY
 Everything is done GENTLY!!
 COMMUNICATE WITH CLIENT FOR PRESSURE
 Focus on relaxation
 Slow stroking, especially on spine
 Palmar kneading
 Slow rhythmical mobilizations
 GTO release
 Stimulate weak muscles
 Decrease edema
 Do not drag
 Reduce contractures
 Support functional contractures if present
 Encourage diaphragmatic breathing
 Reduce spasticity, temporarily
 Maintain joint health and range of motion
 PROM slowly and gently
 DO NOT elicit a stretch reflex hold until resistance release if felt
 Encourage whole body integration
 Stand on affected side
 Encourage feedback!!!
 Apply on both sides of the body, simultaneously if possible
- Self-care Goals
 Yoga, Tai Chi, swimming, walking, etc.
 DO WHATEVER IS COMFORTABLE
 Improve functional ability
 Improve
 Strength
 Flexibility
 Balance
 Maintaining tissue health
 Self-massage for edema
 Cool wraps for edema
 Educate client
 Gangrene  brown or black skin in extremities
 Decubitus ulcers  redness, heat, swelling over bony prominences
 Result of pressure, friction, heat and moisture
 Permanent conditions
 Regular ongoing
 1 hour weekly
 Encourage regular visits to physicians
Other Nervous System Conditions

Fibromyalgia
Fibromyalgia
- Multifactorial condition - Several observed contributing factors - Accurate diagnosis
 Neurotransmitter, hormonal imbalance  HPA axis dysregulation: stress reactions are slower but - Education and support for lifestyle changes
 Sleep disorders last longer  Careful exercise
 Chronic pain  Sleep disorder: little or no stage IV sleep, impairs  Good diet
- Frequently seen with: growth hormone and healing  Good sleep
 Chronic fatigue syndrome  Central sensitization: the CNS becomes more sensitive - Antidepressants
 Irritable bowel syndrome to pain—grows new receptors, suppresses inhibiting - Anti-seizure medications
 Migraine headaches neuro transmitters Medications
 Temporomandibular joint disorders  Neurotransmitter imbalances: substance P and nerve - Analgesics
 Others… growth factor (both for pain sensation) are very high - Antidepressants
Demographics  Tender points: hypotonic spots in predictable locations - Anti-seizure medications
- Estimated at about 7.7% of women, 4.9% of men that relay intense pain signals - Antiparkinsonian drugs (when restless leg syndrome interferes
- 2nd most frequently diagnosed rheumatic disorder - NOT life threatening with sleep)
- Most common among those 60-70 years old  Quality of life threatening Massage Therapy Implications
Signs and Symptoms - “Invisible” pain, easy to disbelieve Risks: Be careful to not over treat
- Stiffness after rest - Frequent overlap with anxiety disorders, depression Benefits: Massage therapy can have many benefits, while being a
- Poor stamina rewarding part of a good self-care strategy
- Fatigue Options: Many kinds of massage therapy appear to help
- “fibro fog” fibromyalgia, but light, gentler work has gotten better results in the
- Widespread, shifting and unpredictable pain research, especially with people new to massage
 Deep ache Research: Massage therapy appears to help pain, anxiety, quality of
 Burning, tingling life, and sleep. Some researchers find best results with a minimum
- Tender points in predictable place of 5 weeks of treatment
- Amplification of all signals, low pain tolerance
Tension Headaches & Migraines

Headaches
- Tension headache is a muscle-contraction-type headache

- Headaches with muscular origins
- Associated with TP and other myofascial pain syndromes
- Headaches are divided into primary and secondary conditions
 Primary headaches are those in which the headache is the condition, such a tension headache or migraine
 Secondary headaches result from an underlying pathology
- Can be life-threatening or a minor complaint
- Other Headaches with Muscular Origins
 Cervicogenic headache
 Unilateral and frontal
 Arises from the neck
 Spinally mediated headache
 Origin in TP (neck and thorax)
 Cervical: facets, interspinous ligament and intervertebral disc
 Stress (including pain) in muscle tendon and ligaments may lead to hyperactivity (increased nerve firing) AKA spinal facilitation
 May present with skin temperature difference of up to 10 degrees
 Also possible in trigeminal and vagus nerve and TMJ, fault head posture, stomach (nausea)
 May have increase tension in trapezius, temporalis and masseter muscles
 Reported with cluster headaches and migraines
 Chronic daily headache (CDH)
 Constant head but fluctuation in pain levels
 Disturbance of sleep
 Associated with: tension headaches, post-traumatic headaches, migraines, drug-induced headaches, fibromyalgia headaches, spinally mediated headaches and temporomandibular headaches
 Chronic pain lowers the quality of life; increase stress and irritability
- Cause of tension headaches are TPs that refer to the head and neck
 Predisposing factors are:
 TP stimuli and perpetuating factors
 Trauma, acute muscle overload, infection (sinusitis), fatigue, chilling of the muscle, referred pain and emotional stress
 Sleep disturbance
 Postural imbalances
 Hyperkyphosis, forward head posture, scoliosis
 TMJ dysfunction
- Medical Treatment
 Treated with analgesics such as Aspirin and Tylenol
 May inject procaine solution into the TP followed by a stretch
 Stress management if CDH
 CDH
 Detoxification from medication is used first to prevent rebound headaches
 PT
 Psychotherapy
 Sleep management
- Symptoms
 3% of people
 63% of men
 86% of women
 Family history 40-50%
 Begin in early adulthood
 Bilateral, diffuse and constant with tension headaches
 Dull or vise-like
 Often referral pattern from TP
 May present with neck and shoulder pain
 CDH have shoulder and periscapular pain
 May be episodic or may or may not be identifiable onset or end
 Episodic are identifiable and occur one after the other
 CDH may be associated with childhood abuse
 Duration: 30 minutes to weeks
 Chronic lasts more than 15 days
 Onset is usually later in the afternoon after latent TP has been activated
 Muscle tenderness and stiffness, hypertonicity in affected muscles and loss of appetite
 SCM TP may experience nausea, vertigo and tinnitus
 Aggravating factors: stress, fatigue, cold, hypoglycemia and poor posture or decreased range of motion of the head and neck
 Infection can perpetuate TP
 During: rest; mild disability, stretching or heat to shoulders for relief
 Associated postural dysfunction
 TMJ dysfunction
- Differentiating Other Headaches
 Later in adulthood (50+) refer out for it’s uncommon
- Contraindications
 DO NOT work deeply during a tension headache
 Avoid vigorous and deep techniques to hyperirritable TP for there may be a kickback
 Kickback may be hours or days after
 Ischemic Compression applied to quickly and deeply, release too quickly and not followed by either passive stretch and heat or slow, active range of motion and heat
- Assessments
 Observation & Postural Assessment
 Look for forward head posture, hyperkyphosis, hyperlordosis, scoliosis or pes planus
 Palpation
 Mastication, neck, shoulder and thoracic muscles for hypertonicity or tenderness
 Muscle of respiration also hypertonic: diaphragm, intercostals, scalenes and SCM
 Ischemia produces areas of coolness in neck and thorax with TP and with spinally mediated headaches
 Range of Motion
 For TMJ, the neck, thorax, shoulder
 AROM and PROM
 Affected by TP
 Reduce range in mandible
 ISO
 Neck, head and shoulder girls are weaker
 Special Tests
 Spinous Process Stress Test
 Spurling’s and cervical compression
 Spurling’s distraction
 Scalene Cramp and Relief Test
 Swallowing Test
- Treatment Goals
 During Headache
 Diaphragmatic breathing
 Hydrotherapy
 Cold may be placed on the referral pattern
 Position
 Supine or side-lying
 Supine towel to cover eyes
 Prone may not be tolerate
 Techniques
 Work within the C’s pain tolerance
 Effleurage
 Stroking
 Fingertip kneading
 Pectoral and posterior neck muscles [upper traps and levators]
 Petrissage on muscle of mastication, facial muscles and scalp
 Joint play is used on hypomobile cervical vertebrae
 PNF
 Finish with…
 Head, neck and shoulder massage with PROM, long-axis traction or GTO of the sub-occipitals
 Reduce TP
 Upper traps refer to the eyes, around the ear, down the lateral neck in the shape of a ?
 Splenius capitis refers to top of head
 Splenius cervicis refer to temporal region and back of neck
 Occipitalis refers to posterior head and locally above the eye
 Suboccipitals refer pain around the ear
 SCM refers to occiput, around the eye, into ear, across the forehead
 Can lead to scalene TP
 Temporalis refers to temporal region and teeth
 Masseter above the eye, into ear, jaw and teeth
 Include synergist and antagonist muscles if pain is not diminished
 Increase ROM
 Increase tissue health
 Between Headaches
 Techniques
 You can increase pressure allowing for joint play and fascial techniques
 Decrease Pain  Decrease sympathetic nervous system firing
 Decrease TP
 Increase range of motion
- Self-Care
 Rest following TP treatment
 Hot bath or contrast towels to the affected muscles
 Diaphragmatic breathing  reduce stress and pain
 Self-massage
 Muscle stripping and ischemic compression and stretching
 Stretching
 Before and after activity
 Strengthening
 Weak muscles
 ISO for various neck muscles can be done with hand
 Perpetuating factors reduced or eliminated
 Postural imbalances and re-education
 DO NOT sleep in prone position
 Stresses neck muscles and facets
 May be refereed to physician for metabolic imbalances, naturopath or nutritionist if nutritional inadequacies, chiropractor or orthotics for structural imbalances
Migraines
- Migraine headache is a paroxysmal neurological disorder with many signs and symptoms
- Half head
- Aura
 Hildegaard von Bingen, a German abbess, scientist, artist and musician, painted and wrote description of “visions experience during the aura of migraine. She described “a great star, most splendid and beautiful, with [an] exceeding multitude of falling
stars” and images of zig-cag lines” known today as scintillating scotoma
- Migraines are divided into 2 main categories:
 Migraine without Aura
 Common migraine
 85%
 24- to 48-hour period before experiences altered CNS activity
 Mood changes, altered sensation, excessive yawning and memory dysfunction
 Originate in the hypothalamus
 Migraine with Aura
 Classic migraine
 15%
 Reduce in cerebral blood flow
 Gradually over 5-20 minutes, lasting for less than 1 hour and resolving with headache
 Auras are visual distortions, flashing lights, zig-zag lines
 Sensory changes like pins and needles around lips and hands
 Auditory disturbances include: hissing or rumbling noises
 Olfactory hallucinations include: strong smells like burning rubber
- Mixed and Transformational Headaches
 Tension headaches and migraines = “mixed headaches” or “transformational headache”
 Episodic evolves into nearly CDH
 Family history, precipitating factor (menstruation and GI symptoms), overuse of medication
 Symptoms
 Pain is bilateral
 20-40 years of age
 Frequency is daily
 Episodic with identifiable endpoints
 Any time of day
 Associated symptoms include: nausea, vomiting, IBS, sleep disturbances and depression
- Cluster Headache
 0.1%
 Men 5 X’s more likely
 Abnormal hypothalamic function
 A group of headaches often once a day for several weeks
 May disappear for months or years
 Rarely family history
 Tobacco use more prevalent
 Symptoms
 Unilateral, periorbital
 Refers to nose, jaw or teeth
 Sharp, burning and boring
 20-40
 1-6 headaches per day in a group
 Last 30 minutes to 3-hours
 Chronic cluster is when the period exceeds 12 months
 Onset 1-3 hours after person goes to sleep
 Ipsilateral autonomic dysfunction
 Nasal congestion, lacrimation, facial swelling and partial Horner’s syndrome of ptosis (drooping eyelid) and miosis (pupil constriction)
 Aggravating factors: alcohol, reduced oxygen levels at high altitudes
 During: agitated, hyperactive (pace the room), difficult to find comfortable spot
 70% respond well to oxygen therapy
- Drug-Associated Headaches
 Medication or drug over-use
 But when taken indiscriminately cause “rebound headaches”
 Often early in the morning when blood levels are lower
 Detoxification often required
 Symptoms
 Bilateral, constant, dull and fluctuating
 Nausea and photophobia are not frequent symptoms
 Often daily, related to drug use, onset from absence
 Memory impairment and medication-related symptoms
 Aggravating: withdrawal
 Severe pain on withdrawal
- Chronic Paroxysmal Hemicrania
 Cluster headaches but more frequent in women
 Symptoms
 Daily, with 14 attacks up to 75 attacks a day
 Symptoms last 1-2 minutes up to 30 minutes
 Daytime onset
 Ipsilateral autonomic dysfunction similar to cluster headaches
 Aggravating factors are head movements
 During: agitated and hyperactive
 Medically: indomethacin
- Trauma-Related Headaches
 Trauma to head, neck or spine
 Fall that creates a shear at SI joint or on the coccyx due to tension placed on dural tube and membranes surrounding the spinal cord and brain
- Migraine in Children
 5%
 Boys are more effected than girls; more prevalent in girls through teens
 Peak between 10-13
 Headache is less prominent instead abdominal pain, cramping, vomiting, episodic vertigo and autonomic symptoms
 Usually 1 or both parents have a history of migraines
- Differentiating Other Types of Headaches
 50+ refer to physician, rare in adults, most likely due to underlying condition
 High-Risk Headaches: Report to Physician
 Onset is new or different
 Worst headache experienced
 Recent acute head trauma
 Worsens over time
 Accompanied by exertion, coughing or straining OR fever and neck rigidity
 Neurological changes: drowsiness, confusion, weakness, ataxia and loss of balance and DTR or Babinski response
 New with Cancer or HIV
 Associated with hypertension
 Warning for:
 Meningitis
 Pregnancy  pre-eclampsia
 Cerebral aneurism (stroke)
 Brain tumor
- Differential Diagnosis
 Diabetes mellitus hypoglycemia
 Temporal arteritis pain
 Lyme disease
 Trigeminal neuralgia pain
 Acute sinusitis pain
 Lower pressure headache syndrome
- Migraine Theories
 Vascular model
 Mechanism trigger vasoconstriction of the intercranial arteries
 Can experience: aura or visual distortion
 After onset, vasodilation occurs in the arteries, producing pain
 Neurogenic therapy (or trigeminovascular system theory)
 Is a disorder of the CNS
 Pain-sensing neuron surrounding blood vessels and dura mater of the brain arise from the trigeminal ganglion and supper cervical dorsal roots C1 and C2
 Migraine attack begins
 Activated by trauma, chemicals, acute hypertension or ischemia
 Results in a reduction of cerebral blood flow (oligemia) starting at the occiput
 This moves in a wave across the cortex 2-3mm per minute
 Aura is associated with this wave
 Blood flow is true for those without an aura
 Pain-sensing neurons react to plasma proteins released by antidromic stimulation of the trigeminal nerve (impulses traveling in the opposite direction of flow)
 This causes cerebral vasodilation and neurogenic inflammation
 The neurons sense this pulsation and inflammation resulting in pain
 Serotonin, a neurochemical helps regulate cerebral vasodilation and vasoconstriction
 C1 and C2 nerve roots origin
 A quarter has postural dysfunctions (hyperlordosis, forward head posture)
 Neck pain from whiplash
- Causes of migraine headaches are:
 Unknown CNS disorder that results in vasodilation and constriction
 Genetics
 Associated with chromosome 19
 Triggering factors:
 Stress (emotional or physical)
 Food and additives
 Chocolate, cheese, citrus fruits, pickles, source cream, onions, sausages, pork, alcoholic beverages (red wine), chocolate, monosodium glutamate and aspartame
 Hunger
 Skipping meals, dieting or eating inadequately
 Medication
 Oral contraceptives
 Nitroglycerine used to treat angina
 Weather change
 Alteration in barometric pressure
 Visual stimuli
 Light
 Auditory stimuli
 Loud sounds
 Smells
 Perfumes, colognes, aftershave, tobacco smoke, paint, diesel fuel and gasoline
 Sleeping
 Too long, too little or at unusual times
 Hormonal shifts
 Ovulation, menstruation, pregnancy or breast-feeding
 Allergies
 Eggs, wheat, meat and milk
 Aggravating Factors:
 Movement
 TP
 Postural dysfunction
- Medical Treatment
 Prescription medication
 Can have adverse effect and can perpetuate factors
 Lots of medication treat today
 Herbs  feverfew, fish oils with omega-3 fatty acids, magnesium
 Migraine sufferer was believed to have a certain psychological profile of:
 Repressed feelings
 Perfectionism
 Anxiety
 AKA “migraine personality”
- Symptoms
 25% of women and 8% of males
 70% family history
 50% report fluid retention
 Increase in stress and fatigue within 24-hour period before onset
 Pain is pulsating and range from moderate to severe
 Unilaterally in 60%
 Dull ache or sensation of pressure gradually localized that becomes more intense and pound over several minutes or hours
 Can lead to hospitalization (status migrainosus)
 Begin in childhood, adolescence or early adulthood
 Rarely greater than 1 per week
 Symptoms last for 4-72 hours
 Onset variable
 Early morning
 Associated symptoms:
 Muscle soreness
 Hypersensitivity to light (photophobia) and sound (phonophobia)
 Autonomic dysfunction
 GI dysfunction (nausea, vomiting and diarrhea)
 Cutaneous vasoconstriction producing cold extremities
 Multiple triggering and aggravating factors
 Number of triggers increase with age
 Withdraws from activity, often quiet, darkened room to suffer pain and disability alone
 Resolves over several hours of sleep or rest
 Intense emotional release or vomiting before abruptly ending
 Period of 24-48 hours “postdrome”
 Feeling fatigued and drained
 Depression
 Muscle achiness
 Emotional volatility
 Chronic pain lowers the quality of life of migraine sufferers
- Contraindications
 During a migraine, massage may be contraindicated depending on the client’s symptoms
 Avoid use of heat on the neck or head during migraines
 Causes vasodilation
 Do not work deeply during a migraine
 Avoid music or bright lights
 Either during or between avoid fragrances, perfumes or essential oils
- Assessments
 Observation and Posture
 Look for forward head posture, hyperkyphosis, hyperlordosis, scoliosis or pes planus
 Palpation
 Neck, shoulder, thoracic and muscle of mastication for hypertonicity and tenderness
 Muscles of respiration (diaphragm, intercostals, scalenes and SCM) for hypertonicity
 Ischemia produces coolness in the skin of the neck or thorax
 Range of Motion
 AROM and PROM
 Reduced neck, thorax, shoulder and mandible
 ISO
 Weakness in neck and shoulder girdle muscles and overuse
 Special Tests
 Vertebral artery test 1ST TEST TO BE DONE
 Spurling’s or Cervical Compression or Distraction
 Stress tests on vertebrae for hypo- or hypermobility
 Blood pressure if 50+
 Kernig’s/Brudzinski test = + with meningitis
- Treatment Goals
 About a degree of relief
 During an Attack
 30-45 minutes to not fatigue C
 Positioning
 Supine or side-lying
 Prone contraindicated blood rushes to head
 Towel used to cover C’s eyes
 Hydrotherapy
 Cold or ice to the head and neck
 Techniques
 Work within C pain tolerance
 May not tolerant work on head, scalp or neck
 Possible hand and foot massage
 Lymphatic drainage for the head and neck
 Stroking, vibrations and fingertip kneading of the shoulder girdle, neck and scalp
 Gentle pressure on frontal, temporal, maxillary and occipital areas
 GTO release for suboccipitals
 Long-axis traction of the neck
 Intermittent muscle stripping and ischemic compression
 Decrease pain
 Decrease TP
 Between Attacks
 Treatment similar but deeper techniques may be used
 Joint mobilization
 5-10 times of grade 1 are appropriate
 Positioning
 Prone can be done
 Decrease TP
 Increase range of motion
 Address postural dysfunction and imbalances
- Self-Care
 Neck, face and scalp
 Hydrotherapy before migraine:
 Hot, full-immersion baths
 Hydrotherapy application during migraine:
 Ice packs applied to the arteries to the scalp and neck to reduce pain
 Aerobic exercise
 Decreases frequency
 Stretching of neck and shoulder muscles
 Refer out… new craniosacral practitioner
Meniere Disease
- Tuning fork on occiput and mastoid process to see
Meniere disease
- A group of signs and symptoms related to inner ear dysfunction - Rapid, unpredictable onset
 Leads to vertigo, tinnitus - Episodes last 20 minutes-24 hours, may fluctuate
Demographics  Hearing loss
- About 615,000 in US  Especially low frequency, may become permanent
- 45,500 diagnoses/year  Tinnitus
 Mostly among those 40-60 years old  “a million crickets”, can interfere with sleep, concentration
Etiology  Aural fullness
- The bony labyrinth leads to the  Pressure in middle ear may come and go
 Ampulla  Rotational vertigo
 Vestibule  World is spinning, floor is tilting
 cochlea  Nystagmus
- Within the bony labyrinth of the ear…  Nausea, vomiting
 2 layers of fluid: Treatment
 Perilymph - Focus on symptomatic control:
 Endolymph  Identify triggers
 These are separated by the membranous labyrinth, found inside the bony labyrinth  Avoid raising blood pressure
- Any disruptions of this delicate environment leads to symptoms in hearing and special orientation  Medications to control nausea, vertigo
(vestibularcohlear nerve)  Disable affected nerve (only if the other ear is unaffected)
- Most agree that Meniere disease involves excess endolymph Medications
 This is idiopathic endolymphatic hydrops - Anti-emetics for nausea
 From… head trauma, allergies, autoimmune disease, infection - Steroidal anti-inflammatories
- The membranous labyrinth ruptures and… - Diuretics
 Endolymph and perilymph mix - Antihistamines
 Nerve endings of vestibulocochlear nerve misfire - Anticholingerics
 Inaccurate signals about our position in space (vestibular branch) - Benzodiazepines
 Loss of hearing, tinnitus (cochlear branch) Massage Therapy Implications
- May progress to affect both ears Risks: No specific risks if the client can get on and off the table without getting dizzy or nauseated; a
chair may be more practical during an episode
Benefits: This is a stressful condition with unpredictable and debilitating episodes. Massage therapy is
unlikely to improve Meniere disease, but it could improve the coping skills of the person who lives with
it.
Seizure Disorders
Seizure disorders
Definition Types of Seizure Disorders: Epilepsy - Myoclonic seizures:
- Any kind of problem that causes seizures - Epilepsy  Bilateral jerking
- Epilepsy is a subtype  Diagnosed when there are 2+ non-febrile seizures, at  Can be pronounced or subtle
 First described in 2000 BCE least 24 hours apart  Usually in babies
 “Demonic possession” until mid 1800s - Classified by part of the brain affected - Atonic seizures:
Demographics  Generalized seizures affect the whole brain  Brief, complete loss of muscle tone
- Many people have a single seizure at some point—this isn’t  Partial seizures affect isolated areas  Risks of falls and injury
seizure disorder Signs and Symptoms: Partial Seizures - Status epilepticus
- 2.3 million adults, 447,000 children with epilepsy in US - Simple partial seizures:  Extended tonic-clonic seizures
- 150,000 new diagnoses/year  No loss of consciousness  Can cause brain damage, death
Etiology  May become weak or numb  Medical emergency
- CNS “lightning storm”:  Some tics, sensory hallucinations, change in vision Treatment
 Interconnecting cerebral neurons discharge electricity, - Complex partial seizures: - Anti-seizure medications
firing other neurons, etc.  Temporal lobe dysfunction: - Some use ketogenic diet
- Triggers vary  Repetitive behaviors (pacing, walking in circles) - Surgery when an identifiable mass causes symptoms
 Sudden change in light levels  Emotional lability - Vagus nerve stimulator
 Flashing, flickering, strobe lights (fan, sun through  Visual, olfactory hallucinations Medications
leaves, etc.) Signs and Symptoms: Generalized Seizures - Anti-seizure medication
 Certain sounds, tones in music - Absence seizures - Barbituates, tranquilizers
 Also anxiety, sleep deprivation, hormonal changes,  Short episodes: “check out” for 5-10 seconds, no Massage Therapy Implications
fever memory of lapse Risks: Someone having a seizure needs to be attended; find out
- Uncoordinated neural activity - Clonic seizures: ahead of time what your client’s preferences are. Medications may
 Electrical signals become increasingly extreme  Jerking movements, upper and lower extremities, with make people lethargic or dizzy; be sure to accommodate for this
 Can go to loss of consciousness or without loss of consciousness Benefits: Massage therapy probably will not change seizures, but it
- Seizure factors: - Tonic seizures: can add to the quality of life for the person who has them.
 Low inhibitory neurotransmitters/high excitatory  Sudden onset of tight muscles, flexion of head, trunk, Research: One study suggests that massage and medication
neurotransmitters extremities for several seconds reduces seizures more effectively than medication alone.
 Mechanical or chemical problem in the brain - Tonic-clonic seizures:
 Traumatic brain injury  “Grand mal”: uncontrolled movement of face, arms,
 Toxic exposures legs, then loss of consciousness and bladder control; 5-
 Alzheimer disease 20 minutes
- Febrile seizures:
 Common childhood event linked to fever
 Usually not connected to a risk for epilepsy
Sleep Disorders
Sleep Disorders
Definition Types of Sleep Disorders Signs and Symptoms
- Any disorder that interferes with: Dyssomnias include: - Excessive daytime sleepiness
 Falling asleep Insomnia - Irritability, mood swings
 Staying asleep - Lack sleep - Difficulty with focus, concentration
 Waking up refreshed  Difficulty falling asleep, staying asleep, sleeping long - Specific symptoms listed in conditions
Demographics enough Treatment
- Up to 30% of the population reports poor quality sleep Transient Insomnia: - Continuous positive airway pressure mask (CPAP) if necessary
- 10% have symptoms - Usually controllable through changing sleep habits - Surgery to open blockage in throat
- Becomes more severe with age, overlapping health problems  Caffeine, alcohol, medications, nicotine withdrawal - Avoid any substances that might further depress respiratory
Etiology  Uncomfortable sleeping room (temperature, noise, drive
- Need for sleep is determined by: light) - Restless leg can be treated with dopamine analogues
 Accumulation of metabolic wastes in the blood  Exercise habits (Parkinson disease medication), if hot baths and massage are
 Secretion of melatonin  Stress not enough
 Circadian rhythm Chronic Insomnia: - Narcolepsy can improve with regular exercise
- Normal sleep cycle is 8-8.5 hours - May be a sign of underlying pathology Medications
- Chronic sleep deprivation leads to several problems:  Hyperthyroidism, fibromyalgia, etc. - Over-the-counter sleep aids
 Higher pain sensitivity Sleep Apnea - Benzodiazepines, nonbenzodiazepines
 Slowed reflexes Obstructive Sleep Apnea: - Anti-anxiety medications
 Lower cognitive skills - Air passage collapses, O2 levels drop, muscles contract - Antidepressants
 Poor immune system activity - May happen hundreds of time per night - Barbiturates
 Fibromyalgia, depression - Excessive daytime sleepiness, morning headache, higher risk of - Parkinson drugs for restless leg syndrome
 Weight pain, diabetes stroke - Stimulants/depressants for narcolepsy
 Etc. Central Sleep Apnea: Massage Therapy Implications
- Daytime sleepiness contributes to: - Decreased respiratory drive Risks: Massage therapy has no specific risks in the context of sleep
 On-the-job injuries - Can cause brain damage, death from O2 deprivation disorders
 Motor vehicle accidents - Linked to heart disease Benefits: Massage therapy may help deal with anxiety and pain that
Stages of Sleep Circadian Rhythm Sleep-Wake Disorders interferes with sleep. Clinicians may recognize signs of obstructive
- Stage I: - Forced to be physically or mentally active, not in a typical sleep apnea
 Easily wakened, hypnic myoclonia light/dark cycle Research: Massage therapy appears to help improve sleep when a
- Stage II:  Shift work person has an underlying condition. One study showed that
 Eyes stop moving: occasional bursts of brain wave  All-nighters postmenopausal women spent more time in stages III and IV and
activity  Changing time zone woke up more refreshed when they got massage.
- Stage III: - Carries all the risks and problems of sleep deprivation
 Brain waves are slower, delta waves appear Restless Leg Syndrome
- Stage IV: - Runs in families
 Only delta waves, growth hormone is secreted - Comorbid with many conditions
- REM sleep: - Constant, crawling, prickling tingling sensation in legs
 Rapid eye movement, HR and BP approach waking - Relieved by movement, rubbing
levels, dreams occur - More noticeable at night
- A healthy sleep cycle goes through each stage and starts again Narcolepsy
at Stage I - “Sleep seizure”
 Distribution of time in each stage varies - In response to intense emotional state
- A full cycle takes about 90 minutes  Hypocretin deficiency
- Overall  Can be genetic or autoimmune
 20-25% REM - 3 basic symptoms:
 50% stage II  Cataplexy
 30% in other stages  Sleep paralysis
 Hypnagogic hallucinations
Vestibular Balance Disorders
Vestibular balance disorders

Definition Types of Vestibular Balance Disorders Signs and Symptoms
- A group of conditions that can disturb the vestibular branch of Benign Paroxysmal Positional Vertigo - Vertigo (perception of spinning)
CN VIII - Small grains of calcium (otoliths = ear rocks) are displaced into - Dizziness (perception of disequilibrium)
 Leads to disabling vertigo semicircular canals - Light-headedness
Demographics  Vertigo can last seconds-minutes - Blurred vision
- Estimated 12.5 in US over age 65 live with balance problems  Special maneuver can correct it - Nausea, GI upset
- About ¼ of all seniors will have at least 1 fall Labyrinthitis - Nystagmus (oscillating eyes)
 Risk of injury or accidental death is high - Inflammation within the bony labyrinth - Changes to blood pressure, heart rate
Etiology  Usually viral, self-limiting Treatment
- CN VIII has 2 branches in the inner ear:  Lasts a few days or weeks, then subsides - Depends on factors
 Cochlear for hearing Acute Vestibular Neuronitis  BPPV: head maneuvers
 Vestibular for balance, coordination - Inflammation of the vestibular branch of CN VIII  Labyrinthitis, neuronitis: anti-nausea drugs
- Vestibular branch starts in vestibule of inner ear  Complication of viral or bacterial condition, or  Vestibular rehabilitation exercises (can help lessen the
 Convergence of semicircular canals autoimmunity risk of falls)
 Receptors are like tiny hairs suspended in jelly  If the cochlear branch is also affected, hearing loss may Medications
 Sway like seaweed when the head turns or tilts develop - Benzodiazepines
 Sensory input coordinates with eyes and Perilymph Fistula - Anti-emetics
proprioceptors for a sense of orientation in space - Inner ear fluid leaks into middle ear - Antivirals
- Changes to the vestibular branch or to the vestibule can cause  Head injury - Antibiotics
vertigo: perception of uncontrollable spinning  Violent sneezing - Steroidal anti-inflammatories
 Fluid pressure (e.g. Meniere disease)  Whiplash-type accident Massage Therapy Implications
 Inflammation  Barotrauma (coming up too quickly while driving) Risks: Getting on and off the table and turning over may trigger
 Injury attack: work with clients to minimize this risk
 Calcium deposits fall out of place Benefits: Compensatory postural habits may be inefficient and
- Other causes of vestibular balance disorders: uncomfortable; massage therapy may be able to help
 Stroke Options: Trigger points in the neck muscles may induce some
 Tumors symptoms of dizziness or vertigo; this may be addressed with
 Multiple sclerosis massage therapy
 Aneurysm
 Migraines
 Allergies
 medications
Circulatory System Conditions

Blood Disorders
Anemia
Anemia
Definition Types of Anemia Continued Types of Anemia Continued
- “lack of blood” Nutritional Anemias Secondary Anemias
- More accurately: lack of oxygen-carrying capacity - The body is missing a key nutrient to make RBCs or hemoglobin - A complication of another disorder
 Shortage of red blood cells  Iron  Cause and effect are sometimes not clear
 Shortage of hemoglobin  Folic acid - The short list of causes includes…
- Not a diagnosis; a description  Vitamin B12 known as pernicious anemia  Ulcers
 Diagnosis is made with the reason for the shortage Hemorrhagic Anemias  Kidney disease
Demographics - From blood loss  Hepatitis
- Affects fertile women twice as often as others - Can be from acute injury  Acute infection
- Common among those over 65 - Chronic slow leak  Blood cancer
Etiology  Ulcers  Leukemia
- Healthy mature RBCs are packed full of hemoglobin  Kidney disease  Myeloma
 So much they don’t even have a nucleus  Heavy menstruation  Lymphoma
 This allows for more O2 capacity Hemolytic Anemias Treatment
 Hemoglobin is built around Fe (iron) - Premature destruction of red blood cells - Treated according to cause
- Anemia develops when either RBCs or hemoglobin are in short - Recognized with…  Nutritional supplements
supply  Splenomegaly  Medications
Signs and Symptoms  Jaundice  Transfusions
- Fatigue  Reticulocytes in the blood  Etc.
- Pallor Aplastic Anemia Medications
- Dyspnea, rapid breathing - Bone marrow activity is suppressed or absent - Oral or injected supplements
- Tachycardia - Every kind of blood cell is affected, leading to… - Steroidal anti-inflammatories
- Intolerance to cold  Low RBC count - Synthetic EPO
- Heart problems  Suppressed immunity Massage Therapy Implications
 Arrhythmia  Bleeding Risks: Be aware of underlying factors that may contraindicate
 Cardiomegaly - Can be from massage therapy; in these cases, work as part of a health care
 Heart failure  Autoimmune attack on bone marrow team for the best outcomes
Types of Anemia  Renal failure Benefits: Massage therapy may help with fatigue and stress, but it
Idiopathic Anemia  Folate deficiency is unlikely to have lasting impact on hemoglobin or red blood cell
- Of unknown cause  Viral infection production. A client who manages anemia successfully can enjoy
 Could be poor nutritional uptake (stress-related)  Exposure to toxins, radiation the same benefits from massage therapy as the rest of the
 Others…? Myelodysplastic Anemia population.
- Similar to aplastic anemia
- Bone marrow makes multitudes of non-functioning cells
- Can be precancerous indicator of
 Leukemia
 Myeloma
Embolism, thrombus & Thrombophlebitis, Deep Vein Thrombosis
Embolism and Thrombus

Definition Types of Thrombus and Embolism
- Embolism: a traveling clot or collection of debris Pulmonary Embolism
- Thrombus: a lodged clot that grows on site - Clots of debris anywhere on the venous side of the systemic circuit can ONLY travel to the lungs
- On the arterial side of the systemic circuit they are a part of cardiovascular disease  Unless there’s a heart defect: patent foramen ovale
- On the venous side of the systemic circuit they are part of the thrombophlebitis, deep vein - When a clot forms in a vein and fragments get knocked loose…
thrombosis  Travels up the vena cava
Etiology  Through the heart chambers
- Platelets constantly roam the circulatory system, looking for rough spots  Through the Pulmonary arteries
 Activated platelets get spiky and stick to the spot  SLAMS into capillaries in the lungs = pulmonary embolism
 They release chemicals that blend with plasma proteins to weave nets - Risk factors:
 Fibrin nets catch passing cells, forming a plug: a clot is born  Other cardiovascular disease
- Platelets also form clots where blood doesn’t move quickly  Recent trauma
- Clots are being formed and dissolved all the time  Bed rest
 Problems develop when pro-thrombotic forces outweigh anti-thrombotic forces  Surgery
- They can form in place (thrombi)  Leading cause of death, complication of surgeries in hospitals
- They can fragment and travel (emboli) - Complications
 Clots cannot pass through capillaries  Repeat event
 When they get stuck, all the cells that should be supplied by flowing blood are at risk  Right-sided heart failure
Signs and Symptoms Arterial Thrombus
- Pulmonary embolism: - A thrombus that forms on the arterial side of the systemic circuit
 Sudden shortness of breath, chest pain, hemoptysis - Complications of atherosclerosis
- Arterial embolism:  Any roughness – like plaque – can trigger clot formation
 In the leg: sharp pain, numbness, weakness  Chronic inflammation
 Tissue may become necrotic  Stress
 In the coronary arteries = heart attack - Clots can…
 In the cerebral arteries = stroke  Grow on site to obstruct the lumen of the artery
 In the renal arteries = renal infarction  Fragment and travel as arterial emboli
Treatment - Can originate as arterial thrombi
- Blood thinners - Can include fragments of plaque, other debris
- Anticoagulants - Can originate with atrial fibrillation or heart valve problems
- Thrombolytics  These allow clots to form inside chambers of the heart
- Surgical extraction of the clot if possible - Brain, coronary arteries, kidneys and legs are most common sites for clots to land
- Supplemental oxygen Massage Therapy Implications
- Compression stockings Risks: if a client has a tendency to form clots, this is a caution for all but the gentlest kinds of hands-on
Medications bodywork. If the client takes medication to manage clotting, be aware that the risk of bruising is high.
- Blood thinners Benefits: People who have been treated for a clotting problem that is now fully resolved are good
- Anticoagulants candidates for massage therapy.
- Thrombolytics Research: Some case reports document emboli or thrombi that may have been disrupted by a
massage treatment.
Thrombophlebitis, Deep Vein Thrombosis

Definition Etiology Continued Treatment
- Veins are obstructed and inflamed because of blood clots - Can be applied to arterial side of the systemic circuit too) - Goals:
- Can form anywhere on the venous side of the systemic circuit - Common precipitators of thrombophlebitis, DVT:  Stop clots from growing
 Mostly in calves, thighs, pelvis  Physical trauma  Prevent fragmenting and emboli
- Thrombophlebitis = superficial veins, with inflammation  Varicose veins  Prevent future clots
 Lesser, greater saphenous  Local infection - Anticoagulants and thrombolytics
- Deep vein thrombosis (DVT)  Physical restriction - Pneumatic compression
 Popliteal, femoral, iliac  Immobility - Vena cava filter
- Venous thromboembolism = DVT + pulmonary embolism  Pregnancy, childbirth - Surgery to remove the clot if necessary
Demographics  Some cancers Medications
- 60-80% of DVT patients have signs of pulmonary embolism  Surgery - Aspirin
Signs and Symptoms  Hormone supplements - Anticoagulants
- Inflammation  Other factors…  Heparin
- Hard cord  Tobacco use, hypertension, paralysis, high altitude,  Warfarin
- Distal edema and discoloration genetic conditions  Thrombolytics
- Skin problems and ulcers - Clots usually form in the leg or pelvis veins, but can form Massage Therapy Implications
- DVT may be subtle or silent elsewhere Risks: Rigorous massage with the intent to promote fluid flow is
Etiology - If patent foramen ovale (a hole in the atrial septum) is present, not a good idea for a person with blood clots, and the symptoms
- Starts with stationary clots in venous system clots may cross to the arterial side to cause… can sometimes be subtle (i.e., unilateral calf pain, heat, or
 Fragments break loose  Stroke coolness). Clients who are taking anti-clotting drugs bruise easily.
 Travel to the lung, cause pulmonary embolism  Heart attack Massage therapy must accommodate these limitations.
- Virchow triad predicts clot risk:  Other arterial embolism Benefits: A client who has successfully treated blood clots in the
 Injury to endothelium (damaged endothelial) - Veins can be permanently damage: post-thrombotic syndrome past is a good candidate for massage therapy.
 Hyper coagulability Research: Most of the published research on massage therapy and
 Venous stasis (impaired blood flow) DVT or thrombophlebitis documents adverse effects.
- Thrombophlebitis is the inflammation of a superficial or deep vein that leads to the formation of a thrombus
- Is NOT a condition that can be treated with massage, this is for EDUCATION and AWARENESS
- Thrombus is a clot which fibrin-based and enmeshed RBC that attaches to BV walls causing coagulation that results in a blood tail
- Can extend up to 20” in veins
- From:
 Venous blood stasis, injury to BV walls
 Can lead to occlusion of the lumen of the BV wall
- 95% develop them in the leg
- SVT and DVT (superficial or deep veins)
- DVT is a great concern
- SVT caused by irritation to the walls
 Presents will localized redness and warmth, and cord-like swelling along the course
 Pain experienced at rest and worsens upon movement
 As it resolves may discolor to brown
- Treatment
 SVT and DVT are similar
- The cause of DVT is venous stasis
 An increase in blood coagulation
- Contributing factors:
 Age: 40+
 Elderly, fractured femur or pelvis
 Young person or athlete
 Prolonged immobilization
 Cardiac failure or stroke and heart disease
 Anesthesia and surgery
 Trauma to leg or pelvis
 Burn patients susceptible to pulmonary embolism (PE)
 Previous history of venous disorders
 Pregnancy or postpartum
 Oral contraceptive
 Diabetes
 Cancer (that are prone to clotting, lung or pancreatic cancer)
 Clotting disorders
- Prevention
 Exercise legs
 No excessive knee and hip flexion
 No sudden or extreme movements
 Diaphragmatic breathing
 Stockings
 Elevating legs
 Especially during long car rides or plane travel
 Anticoagulant, heparin and coumadin, medication
- Special Concern for Hospitals and Nursing Homes
 Those with hip replacements, femoral fracture and pneumatic calf compression (knee surgery, prostate surgery, gynecological surgery, neurosurgery, and C-sec
 Massage is contraindicated if there is leg cramping  pulmonary embolism
- Symptom Picture
 DVT can happen in any vein
 Legs
 Often ankles
 Frequent inflammatory process: heat, redness, swelling and pain, may be accompanied by fever and general malaise
 Local, deep, aching, cramping and throbbing exacerbated by walking
 DVT can break free and become an embolus (mobile clot)
 Entrapped pulmonary vasculature/obstruct blood flow or pulmonary embolism (PE)
 High risk
 Most common from the iliofemoral vein
 10-20% mortality rate
 Symptoms: extreme distress and dyspnea
 Sharp, localized pain in chest behind sternum
 Distention of veins in the neck
 May collapse or go into shock
- Contraindications
 Local massage and massage to affected limb are contraindicated
 Femoral fracture is contraindication
 Write notes if suspected
 Passive and active movements are contraindicated in acute stage
 Refer out
 Coumadin or heparin leads to risk of hemorrhage from any tissue or organ
 Consult physician
 Avoid legs and lower body, aggressive techniques on upper body to avoid bruising
 Known history of DVT or PE
 Recurrent
 Avoid aggressive massage techniques
 Extreme temperature contrast hydrotherapy is not used
 Heat is contraindicated distal to avoid congestion
- Treatment
 Observation
 Signs of inflammation, edema
 Leg pallor
 DVT site
 Palpation
 Local tenderness
 Diminished or absent dorsalis pedis pulse
 Special Tests
 Ramirez’s Test
 Homan’s sign
Hemophilia
Hemophilia
- Collection of genetic disorders - Intracranial bleeding, especially in children - Usually appears at birth
 Absence of plasma proteins needed in the clotting - Bleeding into joint cavities, hemophiliac arthritis  Prolonged bleeding at the umbilical cord
process - Bleeding into muscles, fascial compartments, compartment - Minor childhood injuries bruise and bleed excessively
- Most mutations for hemophilia are on the X chromosome syndrome - Subcutaneous bleeding, nosebleeds, blood in the urine, joint pain
 Males pass to their daughters, who become carriers - Contaminated blood products Treatment
 Women pass the mutation to half their sons  Less of a worry than previously - Prophylactic clotting factor replacements: recombinant factors
 A female can have a typically male version of  Vaccines for hepatitis A, B are recommended  Better than post-injury transfusions
hemophilia, but this is rare Type of Hemophilia - Injected or inhaled desmopressin
Demographics Type A Hemophilia - Exercise (not contact sports!)
- Most are men; 1 type is seen in women - Most common form, about 80% of all cases - Manage weight
- 50%+ have a severe form - Deficiency in clotting factor VIII Medications
- 25% have moderate form - Can develop in adulthood: acquired hemophilia - Prophylactic and as-needed recombinant clotting factors
- 15-20% have mild form Type B Hemophilia - Concentrated clotting factors from donated blood
Etiology - AKA Christmas disease - Desmopressin
- Activated thrombocytes secrete chemicals that interact with - Insufficient clotting factor IX - Antifibrolytics
plasma proteins - About 15% of all cases Massage Therapy Implications
 Plasma proteins and platelet secretions waves fibrin Von Willebrand Disease Risks: Severe hemophilia contraindicates any bodywork that might
nets - Dysfunction of von Willebrand factor: a pro-clotting chemical cause bruising or bleeding; consult with client and healthcare team
 Nets catch passing blood cells to cover the damaged secreted by injured endothelial cells for parameters.
area: a clot - Genetic mutation Benefits: Gentle massage is appropriate for clients with severe
- A person who is deficient in clotting factors cannot form clots - Mild to severe (most are so mild they aren’t recognized) hemophilia; it can also address stress and pain. For those with less
efficiently - Not X-linked severe forms, techniques can be adjusted as necessary.
 They don’t bleed faster than others, but they bleed  Men = women Research: Many scholarly articles suggest that standard or rigorous
longer  Most common inherited bleeding disorder massage therapy is not a first-line approach for hemophilia, because
- Severe hemophilia: <1% of normally clotting factor levels the risks appear to outweigh the benefits
Leukemia
Leukemia
Definition & Demographics Types of Leukemia Continued
- “White blood” Acute Lymphocytic Leukemia - ALL
- Cancer that affects bone marrow function - Type most often found in children, AKA
- Some overlap with lymphoma, depending on the life-phase of the cells  Acute lymphoid leukemia
 Acute myelogenous leukemia: AML  Acute lymphoblastic leukemia
 Most over 65, some children and teens - Usually involves B cells; T cells may be affected
 Chronic myelogenous leukemia: CML - All other bone marrow activity is suppressed
 Mostly children and teens  Immune system is essentially crippled
 Acute lymphocytic leukemia: ALL - Nonfunctioning lymphocytes gather in lymph nodes, cross into CNS
 Mostly adults  Headaches, vomiting, seizures
 Chronic lymphocytic leukemia: CLL Chronic Lymphocytic Leukemia - CLL
 Mostly over 65 - Usually B cells, can be T cells or natural killer cells
Etiology - Mutated cells accumulate in bone marrow, lymph nodes
- Most white blood cells come from myeloid or lymphoid stem cells in bone marrow - Especially common among those exposed to Agent Orange
 WBCs are myeloid or lymphocytic - Can be so non-threatening that no treatment is recommended
- Mutation in the DNA of stem cells leads to production of nonfunctioning WBCs - Signs and Symptoms
 Crowd out functioning cells in bone marrow and blood - Linked to bone marrow dysfunction
- Can be aggressive or slowly progressive - Fatigue, low stamina
- Genetic mutations of stem cells are usually acquired (not inherited)  From anemia, low RBCs
 Exposure to environmental toxins, radiation - Easy bruising, prolonged bleeding
 Electromagnetic fields (?)  Thrombocytopenia
 Some congenital problems increase the risk - Susceptibility to infections
- Untreated leukemia leads to death from excessive bleeding or infection  Low WBCs, especially neutrophil - neutropenia
Types of Leukemia - Other:
Acute Myelogenous Leukemia - AML  Headache, fever, weight loss, abdominal pain, enlarged lymph nodes
- Aggressive cancer of myeloid cells, AKA Treatment
 Acute myeloblastic leukemia - Depends on type
 Acute granulocytic leukemia - Chemotherapy to suppress cancer cell growth
- Mostly mature people - Bone marrow transplant
- Contributing factors:  Autogenic or allogeneic
 Radiation, chemotherapy, benzene - Stem cell implants
- Unlike other leukemias, can form tumors outside bone marrow - Biologic agents, targeted therapy
Chronic Myelogenous Leukemia - CML - Treatments can create severe side effects
- Slowly progressive cancer of myeloid cells, AKA Medications
 Chronic granulocytic leukemia - Chemotherapy agents
 Chronic myeloid leukemia - Biologic therapy agents
- Affects production of myeloid cells - Drugs to mitigate side effects
 Slow immune system activity Massage Therapy Implications
- Signs and symptoms include: Risks: Clients with leukemia have a high risk of bleeding, bruising, infection – these must be respected.
 Abdominal pain Work as part of the health care team to minimize risks, maximize benefits
 Enlarged spleen Benefits: Massage therapy can have many benefits for sleep, appetite, mood, anxiety, and pain
 Night sweats Research: Massage therapy has been seen to reduce some symptoms and to promote relaxation in
 Weight loss leukemia patients
- Can change to become more aggressive, like AML
Myeloma
Myeloma
Definition Types of Myeloma Treatment
- “Marrow tumor” Multiple Myeloma - Can be difficult to treat
- Cancer of B cells in bone marrow - Several tumors at different sites simultaneously - For slow-growing disease in an elderly person: watchful
Demographics - Most common form, 90% of all diagnoses waiting
- Almost always in those who are 50+ years Solitary Myeloma - Chemotherapy and bone marrow transplant
- Men > women, 3:2 - Development of a single plastocytoma Medications
- African Americans have it more than other races Extramedullary Plastocytoma - Chemotherapeutic drugs
Etiology - Myeloma tumors grown outside the bone marrow - Thalidomide and similar drugs to suppress angiogenesis
- Normal B cells migrate from bone marrow to lymph nodes  Skin - Corticosteroids for amyloidosis
- When immature B cells mutate, they proliferate in bone  Muscle - Bisphosphonates for bone density
marrow and form tumors called plastocytomas  Lungs - Synthetic EPO for RBC production
 Spine  elsewhere Massage Therapy Implications
 Pelvis Signs and Symptoms Risks: These patients have a high risk for spontaneous fractures
 Skull - Can be silent, found in routine examination and renal failure. Any massage therapy must accommodate for
- They interfere with normal bone marrow function - Earliest symptoms include… these first. Also, cancer treatments may create other cautions.
 Anemia  Pain Work as part of a health care team for the best outcomes.
 Poor clotting  Signs of CNS pressure Benefits: Gentle massage for stress, pain, anxiety, and sleep may
 Immune system suppression  Spontaneous fractures be a helpful part of a strategy for a person with myeloma.
- Mutated B cell tumors secrete enzymes that corrode bone  Anemia
tissue  Kidney infections
 Spontaneous fractures  M proteins in urine
- Mutated B cells produce non-functioning antibodies  Hypercalcemia
 Monoclonal immunoglobulins, AKA M proteins  Amyloidosis
 Fragments of M proteins can be found in urine  Other organ damage
 Can also cause kidney damage
- Ranges in severity from almost benign to life-threatening
Sickle Cell Disease
Sickle Cell disease

- Autosomal recessive genetic condition - Pain
 Production of abnormal hemoglobin - Fatigue
 Causes RBCs to collapse, lose ability to pass through tight - Shortness of breath
spaces - Pallor
Demographics - Jaundice
- Most common among: Blacks, Hispanics, Greeks, Turkish, and Middle - … and the whole list of complications
Eastern Treatment
Etiology - Limit frequency, severity of sickle cell crises
- Recessive gene:  Mild ones can be treated with pain medication, hot packs
 If a person has 1 gene s/he has the trait, but not the disease  Severe ones need transfusions, opioid drugs
 If 2 people with the trait have children, each one has a 25% - Stem cell transplantation (high risk)
chance of inheriting the gene from each parent - One cancer drug stops sickling; not for children
- With sickle cell disease… - Pain management for children, including massage therapy
 RBCs collapse, can’t get through capillaries Medications
 Shortens their lifespan from 120 days to 10 days - Analgesics
Complications - Prophylactic antibiotics
- Sickle cell crisis - Hydroxyurea
- Organ damage - Folate supplements
- Infection: loss of the spleen creates immune weakness and vulnerability Massage Therapy Implications
- Pneumonia: leading cause of death among children with SCD Risks: The ability to adapt to changes brought about by massage therapy is limited; be sure to keep any challenges to the body
- Gallstones within an appropriate range.
- Vision loss Benefits: For pain release and anxiety reduction without direct physiological impact, massage therapy can be very helpful.
- Acute chest syndrome Research: Massage therapy is a popular choice for people with sickle cell disease; one trial found that massaged children has
- Several others less depression, anxiety, pain and improved function compared to their un-massaged peers.
Vascular Disorders
Aneurysm
Aneurysm
- A permanent bulge in the wall of a blood vessel or the heart - Aneurysms may press against nearby structures, interfere with function - Repair with open or endovascular surgery
 Usually in the aorta or cerebral arteries - Blood may pool and thicken inside: clots can then enter the blood stream  Insertion of a catheter or graft
Demographics - Rupture and internal hemorrhage - Stable abdominal aneurysms:
- 0.5-3% will experience bleeding with silent cerebral aneurysm Types of Aneurysm  Wait and watch
- Aortic aneurysms are linked to age Saccular Medications
 Most people over 60 - Bulges like a rounded sac - Antihypertensives
 Men > women, 3:1 Fusiform - Analgesics
Etiology - Most common for aorta; widened sausage shape Massage Therapy Implications
- Blood pressure is highest in aorta, coronary arteries, arteries Berry Risks: Massage therapy must be adapted to the client’s
that supply the head and brain - Small aneurysm in the brain capacity of adaptation, which is challenged with the
- If the walls of the arteries are weak, they can bulge Dissecting development of aneurysms and other cardiovascular
 This is an aneurysm - Most painful, split between tunica intima/media disease
 It may continue to get bigger Signs and Symptoms Benefits: Massage therapy may help to instill a
 It may rupture – massive internal bleeding - Difficult to find early parasympathetic response for a client whose system is
- Contributing factors:  May not be painful until an emergency compromised
 Compromised smooth muscle tissue, i.e., - Warning signs: Options: Keep bodywork within the client’s adaptive
atherosclerosis  Pressure on another organ capacity, and work to achieve relaxation and lower
 Smoking  Pulsating mass anxiety.
 Congenital weakness  Dysphagia, cough, hoarseness
 Inflammation  Backache
 Syphilis  In brain: headache, numbness, weakness…
 Trauma
Atherosclerosis
Atherosclerosis
Definition Other Risk Factors Treatment
- Subtype of arteriosclerosis - C-reactive protein - Begins with diet, exercise
 Hardening of the arteries from atherosclerotic plaques  Signs of systemic inflammation, predictor for some - Drugs to reduce blood pressure, cholesterol, platelet activity
 Deposits of calcium, cholesterol, and other cardiovascular events - Surgery to correct arteries
substances - Homocysteine  Angioplasty
 Plaques invade artery walls  Amino acid in blood, may contribute to endothelial  Endarterectomy
 Especially coronary arteries and aorta damage  Bypass surgery
 Add spasm and blood clot formation  Body mass index, subtypes of cholesterols, etc. - Percutaneous transmyocardial revascularization
 Bits can fragment and travel downstream: Types of Atherosclerosis Medications
thrombus or embolism Carotid Artery Disease - For cholesterol management
Demographics - Atherosclerosis in carotid arteries  Reductase inhibitors
- Leads to 25% of all deaths - And fragments can travel to the brain (stroke or transient  Fibric acid derivatives
Etiology ischemic attack)  Bile sequestrant drugs
- Steps in development of atherosclerosis: Coronary Artery Disease - Anti-hypertensives
 Endothelial damage - Atherosclerosis in the arteries that supply the cardiac muscle  Beta-blockers
 From hypertension, carbon monoxide, cigarettes,  Occlusion from a clot or traveling fragment can kill  Calcium channel blockers
etc. cardiac cells  ACE inhibitors
 Monocytes arrive, become fixed macrophages Peripheral Artery Disease - Anticoagulants
 Macrophages take up LDL (“Foam cells”) - Development of atherosclerotic plaques anywhere else - Anti-angina drugs
 LDLs are the pro-atherosclerotic form of  Abdomen, legs are most frequent Massage Therapy Implications
cholesterol  Can cause tissue damage Risks: Risks for these clients depend on their capacity for
 Foam cells infiltrate smooth muscle tissue Complications adaptation. Many people have subclinical levels of atherosclerosis.
 They secrete growth factors, muscle cells - Can also be symptoms: circular relationships Make accommodations according to the client’s ability to exercise
proliferate around them  Hypertension (cause and result of atherosclerosis) and general resilience
 Platelets arrive  Aneurysm Benefits: Massage therapy can be an important part of a way to
 Secrete growth factors for proliferation of smooth  Arrhythmia stay healthy for a person who wants to manage atherosclerosis
muscle cells  Thrombus, embolism and heart disease risk.
 Clots form  Angina pectoris Options: Be aware that for people with atherosclerosis risk that
 Vascular spasm  Stable: predictable with exercise work on the upper back can be very welcomed, but that massage
 Plaques form  Unstable: unpredictable, high risk of heart attack that reaches over the anterior side of the trapezius may be risky
 Made of fat, dead foam cells, fibrous cover  Heart attack because it is close to the carotid artery that may be at risk for
 Inflammation may lead to rupture Signs and Symptoms plaques.
Modifiable Risks - Often no signs or symptoms until damage is advanced
- Smoking  Body can compensate with other arteries,
- High cholesterol angiogenesis
- Sedentary lifestyles - Signs are related to poor O2 delivery
- Poorly controlled diabetes  At the heart: poor stamina, shortness of breath, etc.
- Metabolic syndrome
- Anxiety, depression
Hypertension
Hypertension
Definition Types of Hypertension
- AKA high blood pressure Essential Hypertension
- Persistently 140+ systolic, 90+ diastolic - Not wholly dependent on one underlying factor
Demographics - Accounts for 95% of all diagnoses
- About 50% manage it successfully Secondary Hypertension
- 30% probably have pre-hypertension - A temporary complication of another problem
- Men>women until age 45; the it evens out  Pregnancy
- About 50% of those over 60 years old have hypertension  Kidney disease
- Africans have higher rates and more complications  Adrenal tumor
Etiology  Hormone disorder
- Blood pressure is a measure of forces pushing on arteries from inside and from outside - Resolves when the primary problem is managed
 Internal forces Malignant Hypertension
 Plaque or debris on walls - Can be essential or secondary
 Tightness of the artery - Diastolic pressure rises very quickly
 External force - Indicates damage to the circulatory system and a risk for stroke; can be fatal
 Water retention Signs and Symptoms
- Blood pressure cuff translates pressure into mm of mercury - “The silent killer”
 Systole = arteries in contraction - Symptoms are very subtle:
 Diastole = arteries in relaxation  Shortness of breath after mild exercise; headaches, dizziness; swelling of the ankles;
- When pressure is too high, the arteries sustain damage to the tunica intima sweating; anxiety; nosebleeds
 Risk for… Treatment
 Atherosclerosis; aneurysm; stroke; renal failure; heart failure - Frequent untreated or incompletely treated
Complications - Exercise and diet
- Edema  DASH diet can replace a single medication
 Forces fluid out of capillaries, adds to interstitial fluid, increases external pressure on - Medications can have annoying side effects so people may be reluctant to use them
arteries - Most patients use 2 or more medications to control hypertension
- Atherosclerosis Medications
 Damaged endothelium invites white blood cells and plaques; adds to internal pressure on - Diuretics
arteries - Vasodilators
- Stroke - Beta-blockers, alpha blockers
 Can be from embolism or ruptured brain aneurysm Massage Therapy Implications
- Cardiomegaly, heart failure Risks: Unmanaged hypertension carries a long list of complications that may limit massage therapy
 Left ventricle has to work against resistance and becomes large, but not stronger choices. Hypertension medications may make clients feel fatigued, dizzy, lethargic; they may need
- Aneurysm more time after a session to feel normal.
 Bulges in damaged arteries, risk of rupture or clots Benefits: Any client who is encouraged to exercise is probably safe to receive massage therapy.
- Retinopathy Judgments must compare the demands of massage to the client’s activities of daily living. Massage
 Damage to blood vessels that supply the eyes therapy has been seen to have a short-term effect on blood pressure.
Research: Several studies and reviews support the idea that massage therapy may lower blood
pressure, but the best techniques, mechanism and duration of effect are still open questions.
Raynaud Syndrome & Disease
Raynaud Syndrome
Definition Types of Raynaud Syndrome Treatment
- Vasoconstriction of arterioles in the extremities Raynaud Disease - Depends on whether it is primary or secondary
- Raynaud disease = primary - Primary, stand-alone problem - Raynaud disease:
- Raynaud phenomenon = secondary to another condition - Can be triggered by…  Avoid vasoconstrictors (nicotine, caffeine)
Demographics  Stress  Soak in warm water
- May affect 5-10% of the population  Cold  Protect hands in cold settings
- Most have it so mildly they don’t seek help  Mechanical irritations  Manage stress
 Mostly with Raynaud disease, not phenomenon - Slow onset  Medication to dilate vessels
- Women > men - Usually in hands and feet - Raynaud phenomenon:
Etiology Raynaud Phenomenon  Sympathectomy (usually temporary)
- Vasospasm in extremities - Secondary to an underlying problem Medications
 Temporary episodes - Usually more severe than Raynaud disease, higher - Topical applications of vasodilators
 Can become long-lasting risk of complications - Calcium channel blockers, ACE inhibitors
Signs and Symptoms - Associated with… - SSRIs
- Usually bilateral  Arterial disease, i.e., diabetes, Massage Therapy Implications
- Cycle of colors: atherosclerosis Risks: If the situation is complication of another disorder, consider cautions connected
 White/gray  Autoimmune diseases, i.e., lupus, to that. Some medications may make people dizzy or lethargic; accommodate for that
 Blue (indicates low oxygen) scleroderma, rheumatoid arthritis as well. Otherwise, if the skin is healthy and intact, massage therapy is probably safe
 Red (indicates the attack is subsiding)  Sensitivity to some drugs or chemicals Benefits: Raynaud disease indicates massage therapy if the skin is healthy; relaxation
- Attacks of Raynaud phenomenon can lead to atrophy,  A history of frostbite and drawing circulations to the extremities could be helpful
ulcerations, gangrene Options: Many clients with Raynaud disease enjoy hydrotherapy applications like warm
baths or paraffin baths for the affected area
- Allen’s test
- Raynaud’s Phenomenon is a peripheral vascular disorder, which means it affects blood vessels outside the heart and thorax. It occurs secondary to another underlying condition
- Characterized by intense spasm of arteries and arterioles that supply the fingers, sometimes feet
- Vasospasm impair blood supply
- Cause colour changes and sensory symptoms leading to dystrophy in the affected digits
- The cause of Raynaud’s phenomenon is cold or emotional stress
- Raynaud’s phenomenon is secondary to:
 Occlusive arterial disease
 Arteriosclerosis
 Connective tissue disease (ex. systemic scleroderma and lupus erythematosus)
 TOS and other compression syndromes
 Pulmonary hypertension
 Myoedema
 Buerger’s disease (thromboangiitis obliterans) – chronic inflammation of blood vessels int eh limbs and extremities (legs and feet) that causes thrombus formation
 Smoking related
 Previous vessel injury (frostbite or trauma)
 Occupation: vibrating tools, exposure to hot and cold (butchers and kitchen staff)
- Medical treatment
 Address underlying condition
 Vasodilator drugs: calcium channel blockers for vasospasm
 Reduce compromised tissue health
- Raynaud’s Disease is a term used to denote arterial spasm and symptoms similar to Raynaud’s phenomenon, when there is NO underlying, related condition and the blood vessels appear normal
 May begin unilateral, but becomes bilateral within 4-6 months
 Affects women between 18-30
 Symptoms similar to Raynaud’s phenomenon
 Attacks of pallor followed by cyanosis to digits due to vasoconstriction
 Brough on by exposed to cold or emotional stress
 Some risk of rheumatoid arthritis, reduce tissue health and gangrene in the skin and fingertips
 Treatment similar to Raynaud’s phenomenon
- Symptom Picture
 Vasospasm of the blood vessels supplying the hands and feet
 Attack:
 Digits appear white and shiny, often go numb
 Turn red and burning sensation then return to normal
 Slight swelling may occur
 Tissue health is affected
 Muscle atrophy, nails may become brittle and skin will thicken
 Ulcers result in chronic infection, gangrene around the nail and fingertips
- Contraindications
 Cold hydrotherapy
 Stimulating or painful techniques—avoid sympathetic nervous system firing, especially during an attack
 Deep techniques due to tissue health
- Assessments
 Observation
 Tissue and nail health for colour, thickness and ulceration
 Palpation
 Decreased skin temperature
 Possible edema
- Massage
 Physician for risk of thrombus formation and tissue health concerns (gangrene)
 Full body relaxation
 Connective tissue and fascial restrictions
 Interspersed with gentle techniques
 Slow short strokes used on the low back and gluteals
 Over a series of treatments for the limbs
- Self-Care
 Reduce stress/increase relaxation, diaphragmatic breathing, biofeedback
 Avoid cold by wearing gloves and shoes
 Avoid stimulants like food (caffeine), smoking and drugs (birth control, migraine medication and decongestants)
 Nutritionist or naturopath for vitamin E, calcium, magnesium and zinc
 Aerobic exercise to improve circulation (swinging arms up and down)
 Contrast baths
 Avoid triggers
Varicose Veins
- Modify pressure
- Homan’s sign for DVT
Varicose Veins
- Permanently distended, twisted, ropy superficial veins - Chronic venous insufficiency: - Visible, raised bluish lines on the skin of the legs
- Usually in the legs  Varicose ulcers - Anywhere from ankle to groin, often on the medial
 Supporting valves may be compromised  Night cramps side
- The affected vein is stretched and weakened  Coagulation and clot risk - Itching, throbbing, pain and cramping
Demographics  Clots in superficial veins form and melt easily Treatment
- Women > men  Still, distended veins are a risk factor for DVT - Starts with support hose, elastic bandages
- About half of those over 50 years old  Especially when they appeared or worsened - Avoid clothes or equipment that constrict the legs,
- Sedentariness, overweight are risk factors suddenly groin, waist
Etiology Types of Varicose Veins - Recline with feet up when possible
- Blood flow from the legs: Esophageal Varices - Cosmetic surgery is not recommended but...
 Capillaries feed into venules, into small veins - At the distal esophagus - Vein stripping, phlebectomy, sclerosing agents
 Small veins are on the superficial aspect of the leg muscles - A sign of cirrhosis or self-induced vomiting Massage Therapy Implications
 They feed into perforator veins through muscles, into deeper - Risk of internal bleeding Risks: Extreme veins with skin damage may locally
veins - Can be surgically corrected contraindicate direct massage therapy, but if the skin is
 When the leg muscles relax, perforating veins fill Hemorrhoids intact, lotion can be applied with a soothing effect.
 When the leg muscles contract, blood is pushed into deeper - Clusters of vascular tissue around the anus Watch for signs of DVT, however.
veins  Contain veins, capillaries, arterioles Benefits: Massage therapy won’t reverse varicose veins,
 Valves help to prevent backflow - Can develop inside the rectum or externally but gliding pressure with a broad contacting surface
- Valves in superficial veins become weak…  Pain, itching, bleeding with bowel movements can be safe and appropriate.
 From age - Can be surgically removed Options: Hot and cold applications can be helpful
 Gravity Telangiectasias Research: Lymphatic work has been shown to be
 Mechanical obstruction - Permanently dilated capillaries, “spider veins” helpful for range of motion for people with advanced
 Fluid retention from liver, kidney dysfunction - Often at ankles, legs, face varicose veins.
 Congenital weakness, structural anomaly - Usually harmless
- When a vein widens… Varicoceles
 Extra pressure on inferior valves - Dilated veins that supply the spermatic cord
 Distortion and distention - Often painless
 Deeper veins are protected from this by leg muscles - May interfere with fertility, testosterone production
- Surgically corrected
- Varicose means distended or dilated. Therefore, varicose veins are abnormally large and bulging veins. They are caused by the impaired function of the venous valves
- Varicose veins develop when there is an increase in venous pressure, prolonged dilation and BV wall stretch causes the valves to become incompetent and are unable to prevent back-flow
- Leads to impaired circulation and regurgitation of the blood
- Standing aggravates the condition
 This increases pressure 5 times as much as lying supine
- They are NOT spider veins
 Spider veins are chronically dilated capillaries near the skins surface
 But are harmless
- Common in the esophagus common in portal hypertension with cirrhosis of the liver
 Can be fatal
- Those in the rectus or anus are called hemorrhoids
 From constipation, pregnancy and tumors
 Bleeding can occur during defecation
- 2 primary concerns are:
1. Develops SVT
2. Edema and impaired circulation
- Medical treatment
 Injections of tetradecyl sulfate (saline) followed by compression – forced alternation of blood flow
 Surgery to remove  elevation of legs with active foot and ankle movements and walking, support bandages/stockings for several weeks
- Cause of varicose veins are:
 Habits that impair circulation
 Prolonged sitting or standing in one spot, legs being crossed, inactivity, tight garters or girdles
 Increase pressure on pelvic veins
 Weight, heavy lifting, chronic constipation or pregnancy
 Secondary to impaired or blocked blood flow
 DVT, congenital venous malformation
 Heart failure
 Liver dysfunction
 Abdominal tumors
 Vitamin C deficiency
 Can weaken collagen
- Symptom Picture
 Age 40-50
 Men more than women
 Family history
 Often bluish and bulging
 Can become twisting and knotted
 Especially in superficial veins
 Can be asymptomatic
 Possible dull, achy pain, feeling of heaviness and fatigue in legs, difficulty walking
 Leg cramps in calves at night
 May be shiny bluish-brown
- Contraindications
 Deep, specific techniques are contraindicated over varicose veins and on any local tissue
 Are painful and sensitive
 Massage is contraindicated over the esophageal
 Local massage is contraindicated 24 hours after medical treatment for injections
 Surgery consult physician
 Massage to affected leg is contraindicated
- Treatment
 Assessment
 Similar to thrombophlebitis
- Massage
 Elevated legs
 Prone position with pillows under shin and foot
 Supine raise legs above heart
 Pressure to affected leg is modified with lighter pressure
 Promote venous and lymphatic return
 Towards heart, DO NOT send it to limbs
 PROM
- Self-Care
 Stockings
 Non-restrictive clothing at waist or legs
 Do not sit or stand, cross legs or lift heavy items for prolonged periods
 Care to not injure area
 May cause ulceration and bleeding
 Cold water and walking (water treading) can improve circulation with warm socks afterward
 Foot and ankle exercises
 Buerger’s exercise in edema
 Elevate legs above heart 3 times a day for 10 mins
 Bed can be elevated to encourage venous return
Heart Conditions
Heart Attack
Heart Attack
Definition Complications Medications
- A process leading to damage of a portion of cardiac muscle - Often circular: heart attack complications are also contributing - Immediate:
tissue through ischemia factors  Aspirin
- Starved cells are replaced by scar tissue - Atrial, ventricular fibrillations  Analgesics
- Damaged area = infarct - Arrhythmia  Nitroglycerin
- Heart attack = myocardial infarction - Embolism  Thrombolytics, anticoagulants
Demographics - Aneurysm - Aftercare:
- Heart attack is the #1 cause of death for men and women - Heart failure  Nitroglycerin
Etiology - Shock  Anticoagulants, anti-platelets drugs
- Usually begins with atherosclerosis in coronary artery: Signs and Symptoms  Cholesterol management drugs
 A plaque with adhering clots grows until it completely - Angina pectoris, may spread to shoulder, jaw, left arm  Hypertension management drugs
obstructs blood flow – a thrombus  Stable angina: any extra effort causes pain Massage Therapy Implications
 A fragment of plaque or clot travels until it can’t go any  Unstable angina: unpredictable, caused by vascular Risk: The safety of massage therapy for a heart attack survivor
further – an embolism spasm depends on his or her adaptive capacity. People who are fragile
 Newer plaques are more prone to fragmentation - Spreading pain, light-headedness, nausea, sweating have different needs than those who are more resilient.
that older ones - Shortness of breath (with or without chest pain) Benefits: Gentle work that supports homeostasis rather than
 The coronary artery has a prolonged spasm – rare - Stomach, abdominal pain challenges it may be helpful for someone with pain and anxiety
form, usually seen with drug overdose - Remember: a critical blockage can take place over hours – early related to heart disease or heart surgery. A client with a history of
- Risk factors are the same as for other cardiovascular disease: intervention can save lives heart attack but who is physically active is probably a good
- When a portion of the cardiac muscle is killed… Treatment candidate for massage therapy.
 Age and gender - Immediate:
 Family history  Find, eradicate blockage, ASAP
 Diabetes  Thrombolytics
 Hypertension  Balloon angioplasty
 High cholesterol  Administer oxygen, pain relief
 Obesity - Follow-up care:
 Lack of exercise  Decide on a future course of action:
 stress  Requires more attention
- Seriousness of a heart attack depends on…  Prescription anticoagulants and other medications
 Size, location of the infarct  Surgical repair
 How long tissue is deprived of oxygen - Lifestyle changes
Heart Failure (contain Chronic Congestive Heart Failure & Hypertension)

- Foxglove ***
- Shorter sessions for all cardiac conditions
 Don’t let them be prone for longer than 20 minutes, leads to congestion in sinuses
 Side-lying is a better option
Heart Failure
Definition Types of Heart Failure Signs and Symptoms
- Progressive loss of cardiac function seen with age and Left-Sided Heart Failure - Shortness of breath; low stamina; edema; chest pain;
cardiovascular disease - The left ventricle is impaired by obstruction in the systemic indigestion; arrhythmia; distended veins in the neck;
- NOT the same as cardiac arrest circuit restlessness; cold, sweaty skin
Demographics  Atherosclerosis Treatment
- About half of those diagnosed die within 5 years  Hypertension - Rest; low-sodium diet; modified physical activity; medications
- Usually associated with age - Fluid backs up to pulmonary circuit - Surgery to repair valves, wrapping an external support around
- In young people, associated with congenital defect in heart  Pulmonary edema the heart, or heart and lung transplant
function  Shortness of breath Medications
Etiology  Stubborn cough - Anticoagulants
- A healthy heart pumps 200 gallons of blood each day  High risk pneumonia - Beta-blockers, ACE inhibitors
- Resistance in the cardiovascular system leads to compensation Right-Sided Heart Failure - Digitalis
strategies - AKA cor pulmonale - Diuretics
 Cardiac muscle cells grow larger – these eventually - Related to resistance from the pulmonary circuit - Statins
become stiff, less able to work well  Emphysema Massage Therapy Implications
 Secrete epinephrine, norepinephrine to boost heart  History of pulmonary embolism Risks: Clients with heart failure probably have a history of
performance – makes the heart work harder but cause  Pulmonary edema from left-sided heart failure cardiovascular disease. Massage therapy must be carefully adapted
the body to retain salt and water, which increases - Fluid backs up to the rest of the body to their level of resilience. Also be aware that many medications
resistance  Legs, if ambulatory may also require some accommodation with extra time to
- Finally, the myocardium wears out, can’t keep up with needs  Abdomen, if bedridden transition back into full speed.
- Goes into fibrillations, circulatory collapse Biventricular Heart Failure Benefits: Gentle work may help to reduce blood pressure and
- Usually related to underlying history of cardiovascular disease, - End-stage disease perceived stress. While this is a good goal, it is not a substitute for
smoking, diabetes, alcohol and drug abuse - Patient may be a candidate for organ transplant more rigorous care of a complicated situation
Research: The safety of most types of massage therapy for heart
failure patients has not been rigorously tested, but lymphatic work
has been seen to help with edema for this population.
- Hypertension is the elevation of blood pressure above the normal range for a prolonged period of time. It can increase the risk of stroke or heart attack
- Congestive heart failure (also known as heart failure) reflects the heart’s inability to pump sufficient blood to supply the body’s needs
- Understanding Blood Pressure
 Blood Pressure (BP) is the pressure of force of the circulating blood against the blood vessel walls
 Determined by the amount of blood ejected into the aorta (stroke volume) combined with the number of contractions of the heart (heart rate) and takes into account the peripheral resistance that is influenced blood vessels and viscosity of blood
 BP = cardiac output (stroke volume x HR) / totally peripheral resistance
 In hypertension there is an increase in peripheral resistance with lower cardiac output
- Measuring Blood Pressure
 Sphygmomanometer aka blood pressure cuff
 1st sound (thumping or whooshing) is the systolic pressure (SP)
 The last sound hear is the diastolic pressure (DP)
 Systolic pressure
 Maximum pressure/ejection of blood into the aorta
 Influenced by the amount of blood ejected (stroke volume), the speed of ejection and the elasticity in blood vessel walls
 Speed and volume increase when there is less elasticity
 Diastolic pressure
 Minimum pressure maintained in the walls of the aorta BETWEEN contraction
 Influenced by the elasticity of the blood vessel walls, the competency of the aortic valve and the resistance of flow
 Increase in peripheral resistance or rigid arteries (atherosclerosis) increase DP
 Decrease in DP shows the inability of the aortic valve to close, allowing back-flow of blood into the left centricle
 Pulse pressure
 Is the throbbing taken over arteries
 Considered normal is 140 or less SP and 90 or less for DP
- Factors in Maintenance of Healthy Blood Pressure
 Change due to physical activity, positional changes and emotions
 Baroreceptors within blood vessel walls are sensitive to pressure change through stretch in vessel walls
 Located in the neck “carotid sinus” at the arch of aorta
 Also in large vessels, pulmonary blood vessels and heart
 Quick response
 Chemoreceptors monitor the concentration of O, CO2 and H
 Locate in the carotid sinuses and the aorta
 Influence one’s breathing rate
 Autonomic nervous system modified rate and peripheral resistance
 Short term
 Through the vagus nerve both sympathetic (can slow HR) and parasympathetic (increase HR)
 Renin-angiotensin-aldosterone mechanism uses salt retention or salt loss to influence BP
 Renin from the kidneys released due to sympathetic nervous system
 Causes vasoconstriction and salt and water retention
 Hormones
 Renal prostaglandins and vasopressin influence vasoconstriction of blood vessels
- Hypertension
 30% of pop.
 The heart (left ventricle) works harder to pump blood against increase arterial pressure
 Develops more mass and requires more oxygen
 Can damage arterial walls
 Can lead to heart failure
 “silent killer” because it’s asymptomatic
 Symptoms: headaches, SOB or dizziness
 If left untreated can lead to atherosclerosis (“hardening” of the arteries), stroke (the rupture of blood vessels in the brain), heart attack (the presence of blood clots or narrowing of arteries) and peripheral vascular disease (blood vessels in the limbs,
especially leg)  heart failure and kidney failure
 Develops over years or decades
 Increased risk with age because vessels lose elasticity
 Risk Factors for Hypertension
 Those most at risk of develop hypertension are:
 45+; half over 65 years
 Family history of cardiovascular disease, htn, stroke or hyperlipidemia
 Blacks 1/3 more than Caucasians
 Especially those 24-44 (former 18 more likely of kidney failure)
 Men more than women until menopause
 Pregnant women also have an increased risk, especially:
 Teenagers or women over 35
 Black women
 1st pregnancy
 History of htn, diabetes, kidney disease or heart problems
 Mothers who had htn during pregnancy
 10% of those pregnant
 Combination of htn, proteinuria and edema, especially in hands and face
 Aka “pre-eclampsia) or “eclampsia”
 Disappears after birth
 Hypertension is often associated with:
 Heart disease (narrowing of blood vessel walls), angioplasty or bypass surgery to correct narrowing
 Myocardial infarction (heart failure) and post infarction
 Related to higher mortality rate in 2 nd infarction
 Angina pectoris (heart pain due to reduction of blood supply, heart must do more work)
 Left ventricle hypertrophy
 Transient ischemic attacks and stroke
 Arteriosclerosis
 Kidney disorders
 Diabetes
 Especially SP
 Increases cardiovascular disease and atherosclerosis
 Metabolic disorders
 Hyperthyroidism
 Predisposition to lipid and BP abnormalities
 Adrenal tumors
 Lifestyle risk factors for hypertension are:
 Smoking, plaque build-up, 2 times more likely
 Stress, sympathetic constricts BV walls
 High sodium
 Oral contraceptive
 Obesity
 Alcohol
 Physical inactivity
 Risk factors can be cumulative
 Types of Hypertension
 Primary hypertension (idiopathic or essential hypertension)
 Silent
 Long-term
 No relation to other disease
 95% of htn pop.
 Cause unknown
 Secondary hypertension
 Result of underlying pathology (ex. kidney disease, vascular disease or adrenal function/tumor)
 Htn is accelerated and fatal
 Younger people, black men, women with toxemia pregnancy, renal and collagen disease
 The Effects of Massage on Circulation
 Assists in circulation
 Visible hyperemia after prolonged massage in area
 Decrease in BP
 Peripheral vasodilation/decrease in peripheral resistance
 Assessments
 Measuring BP
 Should not smoke or consume caffeine or perform exercise within 30 mins
 Empty bladder
 Same time
 Ignore white coat syndrome
 As Q’s
 Smoke
 Exercise
 Diet
 Medications
 Contact physician to determine is MT is safe and the extend of underlying conditions
 Increasing sympathetic nervous system firing will elevate BP, avoid prolonged painful techniques
 Potentially painful techniques (TP or fascial techniques) are limited and altered with gentle, sooth techniques
 Stimulating techniques like tapotement are avoided
 Client’s neck should not be rotated for prolonged periods of time (can impede blood flow)
 Bilateral treatment of SCM is contraindicated for the same reason
 Full-body application for repetitive long and broad strokes are modified to using short, segmental strokes
 Repetitive, passive, large limb movements in mid- and full ranges should be avoided
 Prolonged elevation of the legs above the heart are not recommended
 Full body lymphatic drainage is contraindicated
 Full-body hydrotherapy or prolonged heat application, especially over pecs, are avoided
 Essential oils: camphor, hyssop, rosemary, sage and thyme, cypress, geranium should not be used
 Massage for Hypertension
 Severity
 Vigilant for signs of distress
 Increase in HR, dizziness, increased respiratory rate, shallow breathing, sweating or facial flushin
 Reduce time in prone position and elevation of upper body while supine
 Painful techniques are performed over a series of treatments, and limited long strokes
 Positioning
 Prone puts pressure on aorta, reduce time
 Side-lying, left side places more stress
 Supine, pillows under trunk, semi-seated position
 Decrease sympathetic nervous system firing (reduce BP)
 Soothing, slow, relaxed, breathing techniques
 Visualization
 Begin with the limbs, short rhythmical strokes
 Self-care for Hypertension
 Relaxation, meditation and biofeedback, 20 mins each day with breathing = decrease in BP
 Moderate aerobic exercise improves cardiovascular health and decreases BP
 Diet
 Stop smoking
- Congestive Heart Failure
 Acute or chronic
 2nd to heart disease, chronic BP, valvular disease and other conditions that place stress on the heart like viral infection and alcoholism
 Life expectancy is 5 years, with medical treatment 5+ years
 Both systolic and diastolic dysfunction
 2/3rds BV is ejected during ventricle contraction, and progressively becomes less
 BV decreases to ¼ or 1/5th leading to sluggish circulation
 Leads to passive congestion, in the heart, liver and limbs
 Heart works harder to contract
 Often goes undetected due to cardiac reserve and maximum output
 This leads to hypertrophy of the heart to contract
 Chronic Congestive Heart Failure
 Risk Factors:
 Pre-existing heart disease
 Physical and emotional stress, dysrhythmia, fever, infection, anemia, thyroid disorders, pregnancy, Paget’s disease, pulmonary disease, poor renal function or steroids
 May not present prior, but after
 Symptoms may appear and disappear, and gets progressively worse
 Symptoms of Left Ventricle
 Pulmonary congestion and edema from increased blood return
 Dyspnea (SOB) influenced by positioning, activity and stress levels  Orthopnea (advanced dyspnea) and paroxysmal nocturnal dyspnea (PND) [feeling of suffocation]
 May cause anxiety, tachypnea (rapid breathing), noisy, wet breathing and profuse sweating
 Accessory muscles start to be used for respiration
 Leads to TP and hypertension
 Hacking cough with frothy, bloody phlegm
 Fatigue, drowsiness and muscular weakness caused by hypoxia (lack of oxygen)
 May go to the brain, cerebral hypoxia
 Increased anxiety, irritability, restlessness, confusion, loss of concentration, impaired memory and insomnia
 Decreased tolerance for exercise
 Symptoms of Right Ventricular Failure
 Edema distal to heart
 Peripheral, ankles, sacral area and back of thighs
 Can cause chronic and pitted edema
 Cyanosis of the digits and nail beds, coldness and pallor
 Ascites (edema in the peritoneal cavity) and weight gain
 Breathing is LESS effected
 Liver and kidney function may be impaired
 Nocturnal urination
 Sleep enlarged
 Abdominal pains, intestinal problems and anorexia
 Distension of jugular veins
 Full-body lymphatic drainage techniques are avoids, as is elevation of the limbs above the heart
 Absolute Contraindication if cardiac edema could lead to pulmonary edema
 Massage for Congestive Heart Failure
 Physician permission
 Sleeping position is a good guide for massage position
 Seated or semi-seated
 Relaxation massage for head, neck and limbs
 AVOID trunk
 Short, segmental strokes
Lymph and Immune System Conditions

Lymph System Conditions
Edema
Edema
- Accumulation of excess fluid between cells - Varies according to source, duration, area
- Can be local or systemic  Soft, boggy, puffy tissue
- Usually due to some combination of…  Could be hot or cold
 Chemical imbalance  Pitting edema - imprint
 Poor circulation  Indurated edema - hard
 Inflammation Treatment
Etiology - Address underlying cause
- Lymph capillaries having openings for ISF to flow in  Could be simple (orthopedic injury)
 Openings are secured with collagen fibers  Could be complex (organ failure)
- When excess ISF develops, the opening to lymph capillaries become wider Medications
- Sometimes this process is overwhelmed: edema - Antihistamines
- Not noticeable until fluid volume is 30% or more above normal - NSAIDs
- Mechanical factors: - Steroidal anti-inflammatories
 Weak heart - Diuretics
 Dysfunctional liver Massage Therapy Implications
 Kidney problems Risks: Most types of edema contraindicate all but the gentlest forms of touch, because the capillaries have already
 Obstruction to venous or lymphatic return been compromised
 Blood clot or debris, removed nodes, tight knee brace… Benefits: Subacute or post-acute musculoskeletal injuries involve edema that may respond well to various types of
- Chemical factors: massage therapy
 Salts, proteins accumulate in ISF, cause water retention Options: The safest modality for clients with edema not due to infection is lymphatic work, but this must be done
 Inflammatory chemicals with appropriate education
Research: Massage therapy that focuses on lymphatic movement is well supported in the research
Lymphangitis
Lymphangitis
- Infection with inflammation of lymphatic capillaries - Starts with signs of local skin infection
- Special risk for those with suppressed immunity, poor - Possible red tracks or lines toward nearest lymph nodes from portal of entry
circulation - Swollen nodes, fever, malaise
- (Also massage therapists, through any lesions on our hands) - Blisters may develop, with tissue damage
Etiology Treatment
- Lymph capillaries are infected - Antibiotics
 Usually a Strep A bacterial infection  As soon as possible to limit risks of complications
 Can be others  Drain or lance abscesses
- Usually comes from a skin injury Medications
 Complication of… - Antibiotics
 Herpes simplex - Analgesics
 Cellulitis - Anti-inflammatories
 Athlete’s foot Massage Therapy Implications
 Diabetes Risks: Someone who is acutely sick is likely to reschedule an appointment. This condition contraindicates massage therapy both because
- Pathogens gain entry, set up infection of the risk of spreading or deepening the infection in the client, and because of the risk of communicability to the therapist
 If it gets to the lymph nodes = lymphadenitis Benefits: Someone who has completely recovered from lymphangitis is a good candidate for massage therapy
 If it gets past the lymph nodes = risk of septicemia Options: This can be an occupational hazard for massage therapists. Avoid it by keeping hands clean and free from hangnails, covering
(blood poisoning) and death any lesions, and staying generally healthy
Lymphoma
Lymphoma
Definition Types of Lymphoma
- Collective name for any cancer that starts in lymph nodes Hodgkin Lymphoma
- Mutation of the DNA in white blood cells - Mutation of B cells
- Can affect the same cells as leukemia - Usually at submandibular, axillary, inguinal nodes
 The delineation between leukemia and lymphoma is not so clear as it used to be - May metastasize to organs
Demographics - Predictable, usually treatable
- Non-Hodgkin lymphoma: Mostly in people over 65 years old Non-Hodgkin Lymphoma
Etiology - Many subtypes
- Begins with mutation of the DNA of targeted cells  B cells, T cells or NK cells
 Usually B cells  Less predictable than Hodgkin lymphoma
 Can be T or natural killer (NK) cells  Harder to treat than Hodgkin lymphoma
 Cells replicate, but they are non-functioning Treatment
 Lymph tissue enlarges - Depends on…
 Mutated cells spread via lymph system  Which cells are affected
 Start tumors in other lymph nodes, bones, spleen, liver and CNS  Stage at diagnosis
- Statistical relationship between lymphoma and…  Grade at diagnosis
 Insecticides; Herbicides; Fertilizers - Chemotherapy
 Hair dye - Radiation
- Risk is higher with history of… - Bone marrow transplant, biologic therapies, etc.
 Epstein Barr virus Medications
 HIV - Chemotherapeutic agents
 Hepatitis B or C - Medication to manage chemotherapy side effects
 Helicobacter pylori - Biologic therapy agents
 Autoimmune disease Massage Therapy Implications
 Immune-suppressant drugs Risks: Any massage therapy that focuses on lymphatic or other fluid movement may be too challenging for a
- Seriousness is rated by what type of cell is mutated, how quickly it replicates client to receive
 Low grade/indolent: growths slowly, may become more aggressive later Benefits: Massage therapy can be helpful in dealing with the challenges of cancer and cancer treatment, if
 Intermediate: aggressive but responsive to treatment the client can tolerate the challenge. Clients who have recovered from lymphoma and are otherwise
 High-grade: aggressive, may become resistant to treatment healthy can enjoy the same benefit from massage therapy as the rest of the population
Signs and Symptoms Research: Many cancer patients, including lymphoma patients, are enthusiastic users of massage therapy,
- Painless enlargement of lymph nodes which has been shown to be helpful for pain, anxiety, depression, and hopelessness.
 Especially at neck, axilla, inguinal area
- Anemia; Fatigue; Weight loss; Night sweats; Itchy skin; Loss of appetite
Mononucleosis
Mononucleosis
- Viral infection that starts in salivary glands, moves to lymph - Can lead to CNS infection - Does not respond to antiviral medications
system  Bell palsy - Treat symptoms
- Usually from Epstein Barr virus (EBV)  Seizures - Rest, supportive therapy
 Can be from cytomegalovirus, herpes zoster, others  Meningitis - Curtail activities for exhaustion, spleen safety
Demographics - Cardiomegaly Medications
- EBV is everywhere – about 90% of American have been - Anemia, thrombocytopenia - Acetaminophen, ibuprofen
exposed by age 25 - Breathing problems - Steroidal anti-inflammatories
- Most people diagnosed with mononucleosis are 15-25 years - Comorbid strep throat – treatment can cause rash Massage Therapy Implications
old - Enlarged spleen, risk of splenic rupture Risks: A person with fever, inflamed lymph nodes and other
- Not everyone exposed to EBV develops mononucleosis - Risk of future lymphoma symptoms is not a good candidate for massage therapy. Lymphatic
Etiology Signs and Symptoms congestion may linger after the infection is over; this also called for
- EBV is fragile outside a host - Vary a lot caution
- Most efficient route to spread is through salivary contact - In young children may be very subtle Benefits: Work that supports recovery without taxing the lymph
 Kissing disease - Most typically: and immune system may be helpful. A person who has fully
- Moves through the body in 2 stages  General fatigue, malaise recovered from mononucleosis can enjoy all the benefits from
1. Virus invades epithelial cells in salivary glands and throat  Fever massage therapy as the rest of the population.
 Incubation = 4-6 weeks; patient is infectious but no  Sore throat
strong symptoms  Enlarged lymph nodes
2. Virus moves on to B cells in lymph nodes, liver, spleen - About half of patients:
- Body produces lots of killer T cells to fight back  Splenomegaly, hepatitis, jaundice
 Causes many symptoms - Can take weeks or months to restore full health
- Virus stays dormant in epithelial cells of the throat
 May reactivate with no symptoms, high
communicability
Immune System Conditions

Allergic Reactions
Allergic Reactions
Definition Types of Allergic Reactions
- Immune system reactions against stimuli that are not hazardous - Anaphylaxis: is a serious, life-threatening allergic reaction. The most common
Demographics anaphylactic reactions are to foods, insect stings, medications and latex. If you are
- About 1,500 deaths/year from allergic reactions allergic to a substance your immune system overreacts to this allergen by releasing
Etiology chemicals that cause allergy symptoms
- Hygiene hypothesis: many children are not exposed to common allergens in early childhood; interferes with  Acute, sever, systemic reaction
proper immune system development  Massive histamine release from mast cells
- Alternative: repeated exposure to some substances can lead to hypersensitivity reactions  Hypotension, edema
 Massage therapists are prone to allergic reaction to ingredients in lotions, especially after long-term  Can interfere with breathing, cause circulatory shock
exposure  Common triggers:
Signs and Symptoms  Antibiotics; blood products; contrast medium in diagnostic imaging;
- Anaphylaxis may cause latex; wasp venom; peanuts; shellfish; others
 Hives, itchiness, flushing, shortness of breath, coughing, wheezing, dysphagia, nausea, bloating, - Angioedema: is an area of swelling of the lower layer of skin and tissue just under
vomiting, diarrhea, slowed heart rate, dizziness, fainting the skin or mucous membranes. The swelling may occur in the face, tongue, larynx,
 Symptoms may develop over hours, appear to subside, and then return more severely abdomen, or arms and legs. Often it is associated with hives, which are swelling
- Angioedema may cause within the upper skin
 Puffy, hot, red skin; may not be itchy; often asymmetrical, rapid onset and subsiding within 72 hours  Acute, rapid swelling of localized area
- MCSS may cause  If it affects the mouth or throat, can interfere with breathing
 Headaches, joint pain, cognitive problems, muscle weakness, dizziness…  Common triggers:
Treatment  Peanuts, tree nuts; chocolate; fish; tomatoes; raw eggs; fresh berries;
- Antihistamines milk; ACE inhibitors; poison ivy, oak, sumac
- Epinephrine, oxygen if necessary - Multiple chemical sensitivity syndrome (MCSS): can include a wide range of
- Steroidal anti-inflammatories symptoms, which some people link to their environment. It’s also known as
- Course of desensitization “environmental illness,” “sick building syndrome,” or “MCS.” Your doctors may call it
Massage Therapy Implications “idiopathic environmental intolerance.”
Risks: Most acute swelling contraindicated massage therapy; if it restricts the airway, this is a medical emergency.  History of exposure to a trigger leads to progressively more extreme
For clients prone to allergic reactions it is important to have hypoallergenic options available to them reactions
Benefits: Chronic allergies can be exhausting; if massage therapy is comfortable to receive, it can greatly add to  Affect multiple body system
quality of life  More triggers accumulate over time
Options: Work to reduce swelling, inflammation in the sinuses if possible, to improve symptoms for respiratory  Mostly seen in people exposed to chemical spills and similar events
allergies  Common triggers
Research: Massage therapists are at risk of developing allergic contact dermatitis with long-term exposure to some  Cigarette smoke, diesel and gasoline exhaust; perfume, cologne;
lubricant ingredients detergents, cleaners; varnish, shellac, etc…
Chronic Fatigue Syndrome
Chronic Fatigue Syndrome

- Collection of signs and symptoms - Unrelenting fatigue - Eat right, exercise, get good sleep
- Affects multiple systems  Unrelieved by sleep or rest - Avoid stressors
- Named in 1988 by CDC  Minimum of 6 months  Emotional and dietary
 Also called… - Plus at least 4 of these: - Education
 Chronic fatigue immune dysfunction syndrome  Poor short-term memory, mental fogginess - Medications for symptomatic treatment
 Myalgic encephalomyelitis  Muscle aches Medications
Demographics  Change in sleep quality, quantity - NSAIDs
- Estimates vary  Headache in a new pattern - Anxiolytics
 Diagnosed in 1 million in US  Tender lymph nodes - Anti-allergy medication
 Probably much more common than that  Joint pain, no inflammation Massage Therapy Implications
Etiology  Recurring sore throat Risks: CFS patients are often easy to over-treat, leaving them
- Not well understood  Post-exertional pain feeling fatigued and unrefreshed
- Factors include… - Common comorbidities: Benefits: Massage therapy may help with sleep, pain, anxiety—as
 Immune system dysfunction – reaction that outlives an  Fibromyalgia long as it is within the client’s capacity for adaption
infection?  Irritable bowel syndrome Research: People with CFS are enthusiastic consumers of massage
 Triggered by mononucleosis or other infections - Also... therapy, so it is important to be knowledgeable about this
 Hypothalamus-pituitary-adrenal axis dysregulation  Multiple chemical sensitivity syndrome condition
 Leads to deficit in cortisol (adrenal exhaustion?)  Interstitial cystitis
 Very extreme allergies  Temporomandibular joint disorder
 Depression or other emotional/psychiatric factors - Symptoms fluctuate, easy to over-exert
Fever
Fever
- AKA pyrexia - Hyperexia
- Abnormally high body temperature  104°+ for adults
 Usually from viral or bacterial infection  Dehydration
 Could be something else  Acidosis
- Controlled change in temperature  Brain damage
 As opposed to other types of hyperthermia - Death from fever at about 112-114°
Etiology - If a fever comes down too quickly it can lead to circulatory shock
- A person is infected with a pathogen Signs and Symptoms
- WBCs find and destroy them - Elevated temperature (101° or higher)
- WBCs display the pathogen markers to other WBCs that secrete pro-inflammatory chemicals  Headache
 Especially interleukin-1  Malaise
- IL-1 interacts with other chemicals, stimulates the hypothalamus to set the thermostat higher  Chills, shivering
- Muscles and glands respond by raising body temperature through capillary constriction, chills, - Small fluctuations without other symptoms are not worrying
shivering, increased metabolism Treatment
- The speak of a fever is the crisis phase - Not always clear when is the best time to intervene
- Then cooling mechanisms take over: the flush phase  Uncomfortable, inconvenient, but usually safe and effective to not treat
- Fever serves a purpose - Fever reducers if necessary
 IL-1 and other cytokines stimulate T cells production, which stimulates B cells and Medications
antibody production - Aspirin ibuprofen, acetaminophen
 Interferon becomes more active with raised temperature Massage Therapy Implications
 Fever limits iron secretion, which slows pathogenic activity Risks: Fever is usually a sign of systemic infection and a reason to reschedule a session – both because of
 Fever raises the heart rate, increasing the distribution of WBCs throughout the the risk of communicability, and because the client is already challenged
system Benefits: Gentle bodywork may help a client with a long-lasting fever feel better, although it may not
 Fever increases cell wall permeability, which speeds chemical reactions impact the source of the problem. Clients who have recovered from fever are good candidates for
massage therapy
HIV/AIDS
HIV / AIDS
Definition Progression Phase 1 Complications
- HIV = human immunodeficiency virus - New infection - Complications of AIDS occurs when HIV has disables normal
- AIDS = acquired immune deficiency syndrome  Virus pools in WBCs immune system function
Demographics  No immune response, no symptoms - Pathogens that don’t threaten others can become deadly
- World wide  Highly communicable because the immune system response is crippled
 35 million are HIV+  Usually lasts 3 weeks to 6 months  Pneumocystis carinii pneumonia
 2.1 new infection/year, 240,000 among children Progression Phase 2  Cytomegalovirus
- US - Acute primary phase  Kaposi sarcoma
 1.3 million are HIV+  Immune system response begins  Non-Hodkin lymphoma
o Up to 14% don’t know  Antibodies for HIV are detectable in the blood  Toxoplasmosis
 50,000 new infections/year  May have symptoms that look like flu or mononucleosis  Herpes simplex
 35,000 people progress from HIV+ to AIDS/year for about 2 weeks  Meningitis
 14,000 deaths/year Progression Phase 3  Herpes zoster… etc.
 80% of US cases are among men - Asymptomatic phase Signs and Symptoms
Etiology  No symptoms or opportunistic disease - Described in the discussion of phase
- HIV enters the body by way of shared fluids: blood, semen,  The infection is progression, and the immune system is Prevention
breast milk, vaginal secretions keeping up - Avoid high-risk behaviors
- It attaches to cells in mucosal epithelium  Medical intervention works to prolong this phase by - Be well educated about high-risk behaviors
- Then it invades a target cell through a receptor called CD 4 inhibiting viral replication - Pre-exposure prophylaxis
 Many cells are CD4+  Can last 1-20 years or more  Antiretroviral drugs reduces the risk of transmission
 HIV usually starts with monocytes and macrophages Progression Phase 4  May be appropriate for those living with an HIV+
 These transport it to lymph nodes and other tissues - AIDS partner
with lots of CD4+ cells  T cell counts drop to <200/cubic mL (normally is 800-  Not risk-free
 Especially helper T cells 1000) Treatment
- HIV is composed of RNA  Opportunistic disease develop - HAART
 Inside a target cell it needs to convert to DNA to HIV Resistance  Highly active antiretroviral therapy
replicate - Some people are long-term non-progressors  Slows viral activity, can’t expel the virus
 This requires an enzyme called transcriptase - 3 main variables for HIV resistance - Not always clear when to begin treatment
 It replicates until the target cell ruptures, releasing new  Host resistance: some people may have fewer CD4  Drugs are toxic, carry major side effects: low blood cell
virus to infect more cells receptor sites count; peripheral neuropathy; pancreatitis; insulin
- HIV can pool and replicate inside immune system cells without  Immune system response: some people have a faster, resistance, etc.
creating an immune system response more aggressive immune system response to the virus Medications
 This is why blood tests may not be accurate for up to 6  Virulence of the virus: some strains of HIV are weak so - Antiretroviral drugs
months after infection – Window phase hosts are better able to manage infection Massage Therapy Implications
- HIV can move from one CD4+ cell to another, destroying tissue Communicability Risks: The person most at risk is the client: be sure to be healthy
along the way - HIV spreads through: Sexual activity; Share needles or when working with someone who is immune-compromised.
 In lymph nodes contaminated equipment that breaks the skin (i.e., tattoo, People who are HIV+ could have a communicable disease as
 In CNS piercing equipment); childbirth, breast feeding complication. Also people who are HIV+ may have side effects to
- HIV is NOT spread through: exposure to tears, sweat, salvia; medication that are issues for massage therapy, like kidney
surfaces that don’t break the skin (i.e., toilet seats, massage problems or peripheral neuropathy
face cradles); Insect vectors; airborne particles Benefits: Massage therapy can be a wonderful therapy to add to
the life of someone who is HIV+ or in end-stage AIDS, as long as it
is adjusted to the resilience of the client
Research: Massage therapy has been seen to help with immune
system activity, depression, and other symptoms related to
HIV/AIDS
- GLOVES AND MASK MANDATORY!!!!
- HIV (human immunodeficiency virus) is the virus that causes AIDS (acquired immune deficiency syndrome)
- The Immune System
 Protects the body against infection and malignant cell growth
 Lymphocytes (WBC) are divided into T-lymphocytes (T-cells) for they originate in the thymus, B-lymphocytes (B-cells, from the bone marrow) and the mreaining lymphocytes are called natural killer cells
 T-cells = viral infection by recognizing antigens on the surface of macrophages
 Subset is called T-4, T-help or CD4 cells
 B-cells eliminate bacteria and toxins by producing antibodies
 Natural killer cells identify and destroy virus-infected cells and tumors
- HIV/AIDS
 1981
 Most common acquired immune deficiency in the world
 Virus selectively infects T-helps cells, destroying
 May be present in brain
 There is a latent period where the person is asymptomatic
 Weakens immune system
 AIDS is when 1 or more “AIDS-defining” diseases or cancers develop
 Cervical cancer – 5 times higher rate  vaginal bleeding between periods and after menopause
 Cryptococcus neoformans – yeast causes meningitis, fever and severe headaches (can also affect skin, lungs and kidneys)
 Cryptosporidium – infection by protozoa  severe diarrhea for months which can lead to death from fluid loss
 Cytomegalovirus (CMV) – opportunistic infection causes fever, sore throat, fatigue, muscle pain and swollen lymph nodes which can lead to pneumonia, hepatitis, colitis, retinitis and blindness
 Kaposi’s sarcoma (KS) – cancer of the capillaries
 Small, purple, raised patches (legs) which become thicken and grow into each other
 May cause ulcers
 Mildly painful
 Skin down into tissues
 Blood-borne lesion that spreads through the lymphatic system
 Appear in eyes and mouth (discomfort)
 GI leading to inability to eat
 Lungs lead to difficulty breathing (death)
 Can lead to edema
 Not curable
 Lymphoma
 Mycobacterium avium intracellular (MAI)/mycrobacterium avium complex (MAC) – opportunistic infection that causes diarrhea, weight loss and fever
 Nervous system infection
 Dementia (subacute encephalitis) can lead to encompass a tremor, spasticity, motor loss and ataxia
 30-50% of the pop.
 Neuropathies like numbness, weakness and pain
 Pneumocystis carinii pneumonia (PCP) – fungal infection in the lungs (soil and buildings)
 Toxoplasma gondii (toxoplasmosis or “toxo”) – organism causes lung and CNS infection with fever, headaches, altered mental status and seizures
 Tuberculosis (TB) – opportunistic bacterial infection of the lungs leading to coughing, malaise, fatigue and night sweats
 Wasting syndrome diarrhea, fever, chronic weakness, weight loss and loss of muscle mass (aka “slim disease” in Africa)
- HIV Transmission
 Viral
 Can survive outside of body
 NOT transmitted through touching or air or cuts and abrasions
 Transmission is through: unprotected sexual intercourse, IV needles and unscreened transfusion, infected blood and blood products, delivery and breast feeding
 HIV must have sufficient amount into bloodstream from bodily fluids
 These are: blood, semen, vaginal secretions and breast milk
 Urine, sweat, tears and saliva DO NOT contain the virus
- HIV/AIDS Statistics
 95% in developing countries
 Globally women 43%
 Mothers 25%
 Young people between 15-24
 North America and Europe, gay or bisexual men, but can infect heterosexual people too
 IV needles through drugs
 Canada: gay and bisexual men dominant
 19% women
 17% aboriginal
 33% injections/drugs
 2/3rds of sub-Saharan African
 Many children and young adults
 southeast Asia
 Latin America and Caribbean
 Latin America gay and bisexual men and drug users
 Caribbean heterosexual transmission
- The Potential Stigma of HIV/AIDS
 The cause of HIV infection/AIDS is a retrovirus
 Contributing factors include infections such as hepatitis B, stress and poor nutrition
- Medically
 Through antibodies blood test
 Continues through assessment of various infections, eye examination and blood tests for viral loads
 Performed periodically and medication is used to treat the stage
 Positive test does not indicate whether the person will develop AIDS
 AIDS is diagnoses with secondary opportunistic infections
 HIV drugs inhibit the ability of the virus to replicate itself through a reverse transcriptase inhibitor and protease inhibitors (affect end of replication)
 Vinblastine is used for KS lesions
 Radiation therapy
 Prophylactical drugs are used to stop secondary infections
 Proper nutrition is important
 Combination of drugs is called a “drug cocktail”
 Increased side-effects
 Acupuncture, vitamin supplements and herbs to reduce stress, improve immune function and reduce side-effects
 However HIV/AIDS is fully preventable, but NO cure exists
- Massage and HIV
 Used for relaxation, stress reduce and quality of life and peripheral neuropathy
 Massage increase the number and activity of natural killer cells, stimulating immunity
 But progression of the virus (through T-cells) remains unchanged
 So only useful for secondary infection
 Can increase weight gain
 Lymphatic drainage for edema (KS)
 Grief and depression (increase in emotions/belief increases immunity)
- Symptom Picture
 May experience short, initial period of flu-like symptoms
 Night sweats, sore throat, muscle pain, headache and swollen lymph nodes
 Infected person may be asymptomatic for a long time
 10-15 years
 CD4 cells decrease, only then are symptoms experience
 Include: swollen lymph nodes, fatigue, recurrent fever, night sweats, diarrhea, decreased appetite, rapid weight loss, mouth sores, vaginal yeast infections and changes in menstrual cycle
 Serious infections and cancers
 Pneumocystis carinii pneumonia and KS (which results in AIDS)
 AIDS dementia
 Peripheral neuropathies
 Can be from HIV or medication use
 Myelin sheath being infected causes it
 Often bilateral
 D4T and AZT can damage axons
 Vitamins B1, B6 and B12
 Affects 6-8% of those asymptomatic
 Occurs in hands and feet
 Mild pain to deep burning, can progress to paralysis
 Exhaustion
 Rhematic manifestation
 Severe joint and muscle pain in the knees, shoulders and elbows
 Unresponsive to analgesic
 Reiter’s syndrome, spondylarthritis and medication-induced (AZT) myopathies
 Fibromyalgia and others
 Periods of relatively good health between bouts of serious illness
- Contraindications
 Do NOT massage over open lesions or tumor
 Fever is contraindication
 Avoid working over insertion site of catheter
 Vinyl gloves are worn with any cuts, sores or abrasions
 Do not overtreat C
 Contagious illness is contraindicated
- Assessment
 Observation and Palpation
 Tissue health
 Tissue wasting
 Atrophy
 Edema (KS)
 Lesions
 Tenderness, numbness and pain with neuropathies
 Joint and muscle pain
- Massage
 Relaxation massage for 30 mins to an hour
 Less with secondary opportunistic infection
 Wheelchair or bedridden, ulcers
 Diaphragmatic breathing is important
 Positioning
 Any
 Hydrotherapy
 Depends on symptoms
 Stress reduction
 Slow, soothing, predictable strokes
 Edema with lymphatic drainage
 Caution with peripheral neuropathy and pressure
 Can treat head, neck and shoulder
 Palliative Massage
 Quality of life
 Best physical, emotional, spiritual, vocational and social life possible
 Goals are: pain reduction and support, particularly emotional
 Do not push C to talk about it, listen
 Tissue and organ system deteriorating and fragile should modify pressure, use gentle and soothing techniques
 Local massage to face, neck and hands
 Family members may also benefit
- Self-care
 Limit exposure to other illnesses
 Thoroughly cook meats, wash fruits and vegetables, wash hands after gardening and cat litter boxes or petting stray animals
 Avoid extreme temperatures (warm socks/boots, sandals if hot, removing shoes several times a day)
 Night hydrotherapy of cool foot or arm baths
 Stress reduction classes and aerobics
 Refer out to naturopath, acupuncturist and nutritionist or physician
 Self-support groups
Autoimmune Disorders
Ankylosing Spondylitis
Ankylosing Spondylitis
- Spinal inflammation leading to stiff joints - Risk of - Exercise, physical therapy, postural training
- Vertebrae can become fused  Osteoporosis - Analgesics
- Sometimes called rheumatoid spondylitis  Vertebral fracture - Anti-inflammatories
- Autoimmune disorder  Nerve pressure, cauda equina syndrome - Disease-modifying anti-rheumatic drugs
Demographics - Loss of lung capacity - Surgery
- Men > women, 3:1 (depending on age)  Shortness of breath Medications
 Symptoms are less severe in women, may be missed  Pneumonia - Analgesics
 Unusual pattern for autoimmune disease  Heart failure - NSAIDs
- Usually diagnosed at 20-40 years - Systemic inflammation may affect eyes, heart, aorta, GI tract, - Oral and injected steroidal anti-inflammatories
- About 500,000 cases in US kidneys - Disease-modifying anti-rheumatic drugs
 Part of a much larger group of autoimmune Signs and Symptoms - Biologic agents to alter immune system activity
spondyloarthropathies - Chronic low back pain Massage Therapy Implications
Etiology  May radiate to legs and feet, look like disc disease Risks: During flares massage therapy must NOT promote
- Autoimmune - Cycles of flare and remission inflammation of any kind. Otherwise, and massage that respects
 Doesn’t show antinuclear antibodies: seronegative  During flare: malaise, fever, iritis bone fragility and limited range of motion may be safe
spondyloarthropathy - Spine and hips become stiff, can progress to other joints Benefits: Between flares massage therapy may be helpful for
 Genetic marker has been found but is not definitive for - Improves with activity (unlike other types of arthritis) maintaining function and managing the stress that accompanies a
all cases chronic, painful, progressive disease
- Begins with chronic inflammation at SI joints Options: Work for range of motion, proprioceptive and breathing,
 Enthesitis: inflammation where as these are high priorities for AS patients
bones/tendons/ligaments attach Research: Massage therapy may improve stiffness and range of
- Inflammation travels up the spine motion for AS patients.
 Disc ossify, vertebral bodies fuse: “bamboo spine”
- Fusions at intervertebral and costal joints
 Distal joints may also be affected
- Flattened lumbar curve, hyperkyphosis
Crohn Disease
Crohn Disease
- Progressive inflammatory autoimmune attack on the GI tract anywhere from mouth to - Cycles of flare and remission
anus - Most common signs of flare:
- May also involve other tissues  Abdominal pain (especially at lower right quadrant)
- Part of inflammatory bowel disease  Cramping
 With ulcerative colitis  Diarrhea (with blood)
Demographics  Bloating
- Usually diagnosed in young adults (age 13-30)  Weight loss
- Whites, Ashkenazi Jews are most often affected  Fever
- Appears to be becoming more common world-wide  Joint pain
Etiology  Ulcers in the mouth, lesions of the skin
- Develop of inflamed patches in GI tract  Pain at anus, with fissures and abscesses
- Usually begins at distal portion of small intestine Treatment
- Factors include: - Aggressive treatment to limit flares and damage
 Pathologic invasion  Aminosalicylates
 Genetic predisposition  Antibiotics
 Immune system dysfunction  Steroidal anti-inflammatories
 Environmental exposure  Immune modifiers
 Dietary triggers  Surgery to remove affected sections of intestines
- Theories:  Often has to be repeated
 Inflammatory response to normal gut bacteria  Dietary adjustments
 Urbanization prevents early exposure to antigens, and later exposure leads to Medications
immune system overreaction - Aminosalicylates
Complications  Mouth, enema, suppository
- Flares of Crohn disease can lead to… - Antibiotics
 Scarring - Oral, injected, topical steroidal anti-inflammatories
 Fistulae, fecal material in the uterus or bladder - Immune-modifying drugs
 Poor absorption of nutrients, osteoporosis Massage Therapy Implications
 Cirrhosis, jaundice, gallstones Risks: During a flare a person may be uncomfortable in some positions on a table, and rigorous massage
 Kidney stones therapy may be too challenging. Be aware that some Crohn disease medications may call for accommodations
 Bleeding or perforated ulcers, peritonitis Benefits: Massage therapy can be helpful for stress relief and digestive comfort during remission
 Abscesses in the GI tract, at the anus Options: Gentle holding of the abdomen is likely to be better received than aggressive petrissage
 Open sores in the mouth
 Sores on the skin of the legs
Wiley
Crohn’s disease – is an inflammation of any part of the gastrointestinal tract in which the inflammation extends from the mucosa through the submucosa, muscularis, and serosa.
Inflammatory bowel disease – inflammation of the gastrointestinal tract that exists in two forms. (1) Crohn’s disease is an inflammation of any part of the gastrointestinal tract in which the inflammation
extends from the mucosa through the submucosa, muscularis, and serosa. (2) Ulcerative colitis is an inflammation of the mucosa of the colon and rectum, usually accompanied by rectal bleeding.
Curiously, cigarette smoking increases the risk of Crohn’s disease but decreases the risk of ulcerative colitis.
Lupus
Lupus
Definition Types of Lupus Signs and Symptoms
- Autoimmune disease attack against many tissues Drug-induced Lupus - Does have a blood marker, not definitive
- Can affect the heart, lungs, kidneys, and brain - Triggered by prescription drugs - 4 or more of the following:
- Can be life-threatening  Hypertension  Fatigue
Demographics  Arrhythmia  Mental confusion, fogginess
- Women > men; 9:1  Psychosis  Alopecia
- Mostly between ages 15-44  Epilepsy  Malar or discoid rash
- Affects about 1.5 million in US - Resolves when medications are discontinued  Photosensitivity
- People of color more than Caucasians Neonatal Lupus  Ulcers of mucous membranes
 Also earlier onset - A mother with lupus passes antibodies to baby  Arthritis in 3 joints or more (hands and feet, NOT spine)
 More severe complications  Rash  Pleurisy, pericarditis
Etiology  Liver problems  Kidney disease
- Autoimmune attack against a variety of tissues  Low blood counts  Headaches, seizures, psychosis
- Often starts at small blood vessels, leads to… - Usually disappears within a few weeks or months  Low blood counts, other blood markers
 Inflammation - No long-term consequences for the baby - Flares are triggers by…
 Clotting Discoid Lupus Erythematosus (DLE)  Exposure to UV light
 Oxygen, nutrient deficit for tissues downstream - Chronic skin disease  Stress
- Factors:  Small scaly red patches  Injury
 Racial/genetic predisposition  Malar rash  Infection
 Hormones  Thin, delicate skin or thickened, discolored skin  Trauma
 Environmental exposures  Some go on to develop systemic lupus erythematosus  Pregnancy (maybe)
- In US and UK, lupus is most common among Black women; in Systemic Lupus Erythematosus (SLE) - Symptoms fluctuate and change over time
Western or Central Africa, lupus is very rare - Antibody attacks against a variety of tissues Treatment
Massage Therapy Implications - Can lead to… - Goals:
Risks: Active flares may involve damaged skin and other tissues,  Arthritis  Promote remission
and swollen, painful joints. Rigorous massage therapy may be too  Renal failure  Limit damage
challenging.  Thrombosis  Improve quality of life
Benefits: Gentle massage therapy that focuses on pain and stress  Psychosis - NSAIDS (can damage kidneys)
relief is a good choice for people with lupus. Those with mild  Headaches - Steroidal anti-inflammatories
version of the condition may be welcome to more intense work.  Seizures - Antimalaria drugs
 Coronary artery disease - Immune-suppressant drugs
 Carditis - Other medications to manage symptoms
 Pleurisy Medications
Mixed Connective Tissue Disease - NSAIDs
- About 10% of lupus patients are comorbid with other - Steroidal anti-inflammatories
autoimmune diseases, especially - Antimalaria drugs
 Scleroderma - Immunosuppressant drugs
 Rheumatoid arthritis (RA + lupus = rhupus) - Drugs for symptomatic relief
 Polymyositis  Steroid cream
 Dermatomyositis  Anticoagulants
 Bisphosphonates
 Etc.
Multiple Sclerosis
Multiple Sclerosis
Definition Types of Multiple Sclerosis Treatments
- Autoimmune condition characterized by inflammation and Benign Multiple Sclerosis - Disease-modifying agents for MS (DMAMS)
degeneration of myelin sheaths in CNS - One episode - Steroidal anti-inflammatories
Demographics - No further progression - Symptomatic control
- Estimated to affect 400,000 in US Relapse/Remitting Multiple Sclerosis - Exercise, physical/occupational therapy
- Women > men, about 3:1 depending on age - Most common form - Eating well, getting good sleep, etc.
- 50% need assistance to walk within 15 years of diagnosis - Cycles of flare/remission Medications
- Can be seen in children - Some recovery occurs during remission - Immunomodulators (DMAMS)
Etiology - Affects 87% of all MS patients - Steroidal anti-inflammatories
- T cells, B cells, antibodies, and cytokines attack myelin in patchy Primary Progressive Multiple Sclerosis - Symptomatic control:
sections of the CNS - Chronic, low-grade progression  Anticholinergics (for bladder control)
- Oligodendrocytes (that make the myelin) multiple to repair - Not marked by flare/remission pattern  Laxatives
damage, eventually fail Secondary Progressive Multiple Sclerosis  Amantadine for fatigue
- Normal myelin is replaced with scar tissue plaques (“sclerosis”) - Cycles of flare/remission  Analgesics for pain
- Electrical impulses are slowed or stopped - Recovery during remission is only partial  Antidepressants as necessary
- Repeated attacks may penetrate to the neuron - Patient has progressive loss of function Massage Therapy Implications
 Leads to permanent damage Progress/Relapsing Multiple Sclerosis Risks: It is easy to trigger painful spasms, event with clients in
- Factors include: - Slow, steady decline remission, with massage therapy that is too deep or too fast. Watch
 Genetic predisposition - Periods of extreme flare for areas of numbness, and be aware that many people with MS do
 Distance from the equator— Malignant Multiple Sclerosis not tolerate sudden changes in temperature
 Availability of vitamin D, made with sun exposure - Fast decline Benefits: Massage therapy can be part of the lifestyle choices of a
 Vitamin D decreases pro-inflammatory cytokines - Disability, even death within weeks or months of diagnosis person with MS to help promote good sleep, and to manage stress
 People with high vitamin D levels develop MS less Signs and Symptoms and depression
frequently than others - “The Great Imitator”, most dependable signs include: Options: Some MS patients have weakness, spasm in extremities;
 Gradual or sudden weakness; spasm—stiffness or massage therapy here may help with this symptom
cramping; changes in sensation: numbness or Research: Massage therapy may help with stress, pain, mood, and
paresthesia; optic neuritis, vision impairment; constipation. Its affect on functional goals may be less useful.
urological dysfunction; sexual dysfunction; difficulty
walking; loss of cognitive function; depression;
digestive disturbance; fatigue
- Multiple sclerosis (MS) is a condition in which demyelination of the nerves occur

- Begins with an inflammatory process that results in demyelination of nerve axons
that cause scar tissue formation (sclerotic plaques) that slow, disrupt or block
nerve transmission
- Myelin is able to regenerate through the work of oligodendrocytes
- Depends on the location of the lesion in the central nervous system and extent of
the lesion
 White matter affected in CNS
 Lesions most commonly found in the brain stem, cerebellum and spinal cord
 Optic and trigeminal cranial nerves
 Optic = color blindness, visual field defects and diplopia (double vision)
 Trigeminal = trigeminal neuralgia
- Average onset is 20-40 (can occur 15-45)
- Women more than men
- No cure
- Different types of MS
 Benign MS
 Mild
 Few exacerbations followed by recovery
 C remains asymptomatic
 Attack-remitting MS
 Difficult to diagnosis
 Repeat cycles of exacerbation and remission
 Symptoms: double vision, slurred speech, numbness and tingling anywhere
 Benign or mild attack-remitting MS
 Mild disability when attack subsides
 Chronic progressive attack-remitting MS
 Increased symptoms following attack
 Remission is gradually less frequent
 Disability odds increase
 Acute progressive MS
 Rapid progression of symptoms and disability
 Can be fatal
 Least common
- Causes of MS
 Genetic Factor
 Gene is responsible for a predisposition
 25-30% siblings
 Increased relatives
 Environmental Factor
 North America and Northern Europe
 Closer to the equator the less likely
 Viral Factor
 Immunological Factor
 Over activity of white cells leads to attacks against myelin
 Or autoimmune disorder
 Exacerbate symptoms:
 Deficiencies in zinc, vitamin B16 and B12 or essential fatty acids
 Essential fatty acids are components of myelin
 Amalgam dental filling
 Mercury and lead can pass through BBB
 Food allergies to dairy and unsaturated fats
 Stressful events, overexertion, heat, fever, injury and emotional upset
- Treatment
 Involve diet, nutrition, exercise, support groups, stress reduction and realistic activities
 Limit fatigue, spasticity or muscle weakness
 Medication: Betaseron (particularly in attack-remitting)
 Massage Therapy improves physical awareness, temporarily decreases spasticity, improves soft tissue and joint health, decreases contractures, reduces stress and emotional support and well-being
- Symptoms
 No client will have all symptoms listed because it attacks at different lesion sites
 Fatigue
 Can also increase tingling and numbness, blurred vision or slurred speech
 Normal after vigorous activity
 “MS fatigue” used to describe the lassitude or feeling of sudden sleepiness after almost no activity
 Spasticity
 Weakness can come from lesion site in spinal cord (partial or complete)
 Experienced more uni than bilaterally
 Proprioception
 Tremors occur when person is activity attempting to move
 Range in severity
 Gait
 Circumduction gait, and dragging of the foot
 Altered posture
 Wheelchair, scoliosis or hyperkyphosis can develop
 Contractures
 Compensatory changes
 Occur in unaffected or overused limb
 C may use a cane, a walker or a wheelchair or alternating between these methods
 Paresthesia
 Numbness, tingling or burning
 Pain can be a primary symptoms of trigeminal neuralgia
 Can lead to or because of gait, posture, cane, etc.
 Cold extremities or sweating abnormalities
 Autonomic dysfunction
 Edema may be present  more common in wheelchair due to insufficient contraction of vessels
 Long standing edema (pitted edema) can lead to tissue fragility
 Could develop ulcers
 Mood swings
 Depression, euphoria and cognitive problems (forgetfulness and inattentiveness
 Other symptoms
 Vertigo  loss of balance and lack of coordination
 Diplopia, nystagmus, decreased visual acuity, reduced visual field and colour blindness
 Speech disturbances such as dysarthria and slurring
 Bladder dysfunction
 UTI’s
 Bowel dysfunction and constipation
- Contraindications
 Techniques or modalities that will fatigue the client are contraindications
 Painful techniques that increase sympathetic nerve firing and exacerbate fatigue
 Heat applied over a large area will affect nerve conduction and exacerbate fatigue
 Deep techniques are contraindicated in areas with altered sensation
 If decubitus ulcers are present local massage is contraindicated
 Red, inflamed area over bony prominences refer out
- Assessments
 Observation & Palpation
 There is no typical MS client
 Range of Motion
 AROM and PROM will reveal a decrease in range of motion, if spasticity or weakness is present
 The more severe the less range of motion
 ISO will NOT yield useful information in the presence of spasticity
 MS C’s sometimes present with weak side and strong side
 Special Tests
 Sensory Testing
 Dermatome Testing
 Proprioception Testing  fine motor skills
 Finger to nose Tests
 Heel to shin Test
 2-point Discrimination Test  temperature
 Specific orthopedic tests
 If spasticity is present test may not yield viable results
- Treatment Goals
 Therapist will ALWAYS aim to decrease sympathetic nervous system firing, avoiding inducing fatigue and provide carrying touch and a supportive environment
 Positioning
 May be confined to wheelchair
 More spasticity present the fewer the changes
 Head in neutral position ALWAYS
 MOVE LIMBS SLOWLY AND GENTLE
 Hydrotherapy
 Cool and cold applications
 Appropriate for edema
 Reduce spasticity
 Depress afferent and efferent firing
 Heat can induce fatigue and other symptoms
 Use mild warmth for TP, but monitor for negative effects
 Techniques to reduce spasticity:
 Slow rhythmical Swedish techniques such as stroking and palmar kneading
 Particularly on the spine
 Slow rhythmical shaking of the limb
 Golgi tendon organ release if accessible
 Slow steady performance of passive range of motion
 Avoid exacerbating spasticity
 Decrease spasticity
 Maintain proper body alignment
 Maintain joint health and range of motion
 Prevent fatigue
 Improve and maintain tissue health
 Decrease edema
 Be vigilant for decubitis ulcers
 Limit contractures
- Self-care Goals
 Increase functional ability through improving strength, range of motion and balance
 Educate about the maintenance of tissue health
 1-hour weekly
 Stress reduction, increased function and greater sense of well-being
 If tendinitis or bursitis is present 2 and a half hour treatments may be appropriate
 Life expectancy is 25-30 years
 Women fare better than men
 A person with sensory symptoms at onset fares better than one with motor symptoms at onset
 Incoordination at or near onset is the least favorable onset
 Long remission between the first and second attacks is favorable
 The state of the disability 5 years after onset correlates with the progression that can be expected in the following 5-10 years
Psoriasis
Psoriasis
Definition Types of Psoriasis Complications
- Chronic skin disease Plaque Psoriasis - Rarely life-threatening
- Skin cells replicate too quickly - Most common version (80% of all patients) - Can be uncomfortable, disfiguring
 Every 3-4 days, instead of every 28-32 days - Small to large lesions that itch and flake - 10-30% develop psoriatic arthritis,
- New cells accumulate into itchy, scaly plaques Guttate Psoriasis  Can be treated by massage therapists like rheumatoid
 Trunk, elbows, knees - Triggered by viral or bacterial infection arthritis
 Can be elsewhere - Small, round lesions (“raindrops”) Treatment
- Most agree that psoriasis is an autoimmune disease Pustular Psoriasis - No permanent cure, treatments may need to be changed when
Demographics - Small pus-filled noninfectious blisters tolerance develops
- About 1 million in US live with psoriasis - Mostly palms and soles - Topical applications
- Men = women - Risk of secondary infection - Biologic therapies
Etiology Inverse Psoriasis - Some herbal remedies may help
- Factors: - At skin folds  Capsaicin + aloe vera as topical applications
 Genetic predisposition - Skin is red, shiny, vulnerable to cutaneous yeast or fungal  Dong quai
 Producing high levels of pro-inflammatory infection  Milk thistle
chemicals Erythrodermic Psoriasis Medications
 Overlap with metabolic syndrome, diabetes, heart - Serious, triggered by - Topical applications of medicated creams
disease  Sun exposure - Vitamin D analog cream
 Immune system dysfunction  Topical steroid use or cessation - Injections of steroidal anti-inflammatories into lesions
 T cells stimulate inflammation and new capillary - Can cause damage, fluid loss - Psoralen + UV light = PUVA
growth - May be medical emergency - Biologic agents to alter immune system activity
 Environmental triggers Signs and Symptoms Massage Therapy Implications
 Stress - May run in cycles of flare and remission Risks: Massage therapy may exacerbate itching; be careful about
 Infection - Lesions have well-defined edges this. Watch for open lesions and the risk of infection.
 Medications - May have a silvery scale Benefits: Massage therapy can be a welcome experience for
 Weather - Mostly on trunk, scalp, elbows, knees someone who has skin problems.
 Skin injury  Can be on palms, soles, elsewhere Options: Use hypoallergenic lubricant
Rheumatoid Arthritis
Rheumatoid Arthritis
- Autoimmune attack on synovial membranes - Often comorbid with osteoporosis - Important to start treatment as soon as possible to limit
- Inflammation of other tissues as well  RA medications can cause bone density loss progression
Demographics  Being mature woman involves bone density loss - Goals:
- Affects about 3.1 million in US  Having less movement due to pain causes bone density  Reduce pain
- Women > men, 3:1 loss  Limit inflammation
Etiology - Risk of unstable joints + risk of easy fracture, slow healing  Halt joint damage
- Autoimmune attack on synovial membranes of certain joints Types of Rheumatoid Arthritis  Improve function
 May also affect other tissues - Standard (as discussed) - Medications to limit progression
- Synovial membranes under attack - Juvenile rheumatoid arthritis: - Exercise, dietary adjustments, stress management
 Swelling, heat, pain, loss of function  At few joints = pauciarticular JRA - Surgery if necessary
 B cells, T cells, antibodies, pro-inflammatory chemicals  At 2 of more joints = polyarticular JRA Medications
are present  Or systemic JRA (still disease) - NSAIDs, Cox-2 inhibitors
 Fluid accumulates inside joint capsule (painful) Signs and Symptoms - Analgesics
 Inflamed membrane releases corrosive enzymes that - Malaise leading up to 1st flare - Steroidal anti-inflammatories
damage cartilage and bone, tendons and ligaments - Vague pain that becomes sharp, specific joint pain - Disease-modifying anti-rheumatic drugs
 Leading to bony deformation - Rheumatic nodules on pressure-bearing areas - Biologic agents to alter immune system activity
- In addition to synovial membranes… - During flare: Massage Therapy Implications
 Sclera may develop rheumatic nodules  Joints are visibly, palpably inflamed Risks: During a flare, RA contraindicates most types of bodywork
 Sjogren syndrome  They may improve with heat and movement except for very gentle, soothing strokes and gentle manipulations
 Pleuritis, pericarditis  Knuckles in hands and toes of joints. Medications may impact decisions
 Liver inflammation (hepatitis)  Ankles, wrists, rarely at knees Benefits: Massage therapy may be helpful for pain, stress, anxiety,
 Vasculitis  In the neck it can be dangerous and muscle tension
 Raynaud phenomenon Options: Range of motions exercises that are painless can be
 Skin ulcers especially helpful for RA patients. Also focus massage therapy on
 Intestinal ulcers muscles and tendons that cross painful joints
 Internal bleeding Research: Moderate pressure massage therapy for RA patients in
 Bursitis remission was well received.
 anemia
- Structural damage to bones: easy dislocations and collapse
 Especially dangerous at C1-C2
Scleroderma
Ulcerative Colitis
Ulcerative Colitis
- Autoimmune attack on lining of the colon - Depends on how much of the bowel is affected
- Single continuous lesion, restricted to colon - Cycles of flare and remission
- “inflammatory bowel disease” refers to both ulcerative colitis and Crohn - During flare:
disease  Painful chronic diarrhea, blood and pus in stools
Demographics  Abdominal cramping
- Far more common in Westernized countries  Tenesmus (the sense of needing to have a bowel movement)
- Whites more than other groups  Loss of appetite
- Women > men, but not by much  Fever
Etiology - During remission:
- Autoimmune  Mild pain
 Genetic factors  A need to avoid triggers of cramping, discomfort
 Possible triggered by inflammatory response to gut bacteria Treatment
- Begins at rectum - Begins with medication to reduce the severity and frequency of flares
 Attack on superficial layer of the colon - Steroids, immune suppressants, nicotine patches
 Shallow ulcers that may become infected - Surgery to remove the affected section of the bowel
 Limited colon function  May lead to needing a colostomy bag
- Classified by what parts of the colon are affected Medications
 Ulcerative proctitis = rectum - Oral, suppository or enema applications of Aminosalicylates
 Proctosigmoiditis = progression to sigmoid - Oral or injected steroidal anti-inflammatories
 Left-sided colitis - Immune-modifying drugs
 Pancolitis = whole colon is affected Massage Therapy Implications
- Affected area is continuous and progressive, not patchy Risks: UC in a flared state contraindicates massage therapy, at least locally. At other times it is important to remember that
Complications the colon has been damaged and should not be pinned down during intrusive abdominal work. Clients who use colostomy
- Tissues outside the GI tract may become inflamed during flare bags may need adjustments in positioning
 Gallbladder ducts Benefits: Someone who has UC in remission can receive any kind of massage therapy that is comfortable. Someone who has
 Osteoporosis from poor absorption fully recovered is a good candidate for massage therapy.
 Anemia Options: Clients with UC or other digestive system upset often appreciated gently stroking or holding over the abdomen that
 Kidney stones allows them to experience this part of their body in a positive way
 Uveitis Research: Many people who live with inflammatory bowel disease seek out massage therapy as part of their treatment plan or
 Skin lesions coping strategy, so it is important to be knowledgeable about these conditions
- High risk for colon cancer
Wiley
Colitis – Inflammation of the mucosa of the colon and rectum in which absorption of water and salts is reduced, producing watery, bloody feces and, in severe cases, dehydration and salt depletion. Spasms
of the irritated muscularis produce cramps. It is thought to be an autoimmune condition.
Ulcerative colitis – is an inflammation of the mucosa of the colon and rectum, usually accompanied by rectal bleeding. Curiously, cigarette smoking increases the risk of Crohn’s disease but decreases the risk
of ulcerative colitis.
Respiratory System Conditions

Infectious Respiratory Disorders
Acute Bronchitis
Acute Bronchitis
- AKA chest cold - Persistent cough - NSAIDs
- Self-limiting inflammation of the bronchial tree - Clear or opaque sputum, wheezing, nasal congestion - Cough suppressants
- Usually resolves within 10 days of onset - Headache, chest pain - Bronchodilators
Demographics - Fever - Antibiotics if necessary
- Less common that cold or flu - Muscle aches Massage Therapy Implications
Etiology - Fatigue Risks: Delay any challenging massage therapy until after the
- Bronchi are irritated by infectious agent Complications infection has passed. The client may be uncomfortable lying flat
 Usually a complication of cold or flu (viral) - Pneumonia may be present if… until the coughing phase has subsided
 Can be bacterial or fungal  Fever > 101° and persistent Benefits: Gentle, non-demanding massage therapy may be
 Can be a result of chronic irritation (opportunistic  Sputum becomes opaque and blood-streaked appropriate for a person with acute bronchitis, with caution for
infection) Treatment communicability. During recovery, massage therapy may help with
- Self-limiting - Rest, fluids, humid air fatigue and quality of sleep.
 No permanent structural changes to the lungs - Antibiotics are not effective unless it is a bacterial infection Options: Within tolerance, focus on breathing muscles for best
o This is NOT true of chronic bronchitis - Cough suppressants may help with sleep, but may not shorten efficiency and least effort.
the duration of the infection
Common Cold
Common Cold
- Viral infection of the upper respiratory tract - Can complicate to secondary infection - NSAIDs
- AKA Coryza; upper respiratory tract infection; viral rhinitis  Ear infection - Cough suppressants
Demographics  Laryngitis - Decongestants
- Only humans and higher primates get colds (!)  Acute bronchitis - Zinc lozenges
Etiology  Sinusitis Massage Therapy Implications
- Most of common cold pathogens are rhinoviruses  Pneumonia Risks: Delay rigorous massage therapy until the infection
 Could also be coronavirus, adenovirus, respiratory syncytial virus Signs and Symptoms has peaked. Afterwards, be aware that sinuses may be
- Usually low-grade, not threatening - Stuffy, runny nose painful, and make appropriate accommodations. Working
 Some can be severe and life-threatening, especially for children - Sneezing with a client who is just getting over a cold or flu may
- Virus enters the nose; cilia carry it to throat - Sore throat exacerbate symptoms for a day, and then speed healing
 Target cells in the lymphoid tissue of adenoids - Dry cough (this is purely anecdotal) – it is important to warn of this
- From exposure to symptoms: about 12 hours - Headache possibility
- Infected cells trigger destructive immune system response - Mild fever Benefits: Gentle work during an infection may be soothing,
 Inflammatory chemicals - Resolve within 2 weeks, but cough may linger and sleep-promoting, if precautions protect the therapist
 Aggressive cells Treatment from catching the cold. Afterwards, massage therapy may
 Infected cells and neighbors are sacrificed - Rest, fluids, isolation to prevent communicability help with sinus pain and general recovery.
 This causes many of the characteristic symptoms - Clean humidifiers
- Viruses are viable for several hours outside a host - OTC drugs can relieve symptoms, may prolong infection
- Airborne with coughing/sneezing, also easy to spread from touching surfaces
 Doorknob, keyboard, money
 Then rubbing the nose or eyes; touching the mouth
- Prevention: keep hands clean
Influenza
Influenza
Definition Types of Influenza Treatment
- Viral infection of the respiratory tract Seasonal Flu - Rest, liquids, humid air
- Often irritating but not dangerous, but can be life-threatening - Most common form - OTC drugs may help with symptoms but don’t shorten the
for vulnerable patients - Can involve several different type A viruses infection
Etiology - Fall through spring - Neti pots, rinsing devices (if they are clean)
- Gain access to mouth, eyes, nose H5N1 Flu - Neuraminidase inhibitors can shorten
 Can be airborne or by touch - AKA Avian flu - Flu vaccines are compiled the previous year to protect against
- Travel to mucous-producing cells in the respiratory tract - Passes from wild water birds to domestic poultry predicted predominant viruses
- Immune system response creates most symptoms - Rarely passes from poultry to humans Medications
- Communicable from exposure through infection and recovery  Requires prolonged close contact with live, sick bird - NSAIDs
- Type A flu viruses easily mutate - VERY rarely passes from human to human - Antiviral medications
- Can move from animals to humans  Only a few cases on record, but dangerous when it does - Neuraminidase inhibitors
- Labeled by proteins on outer coat: - Extremely virulent with about 30% mortality rate Massage Therapy Implications
 Hemagglutinin H1N1 Flu Risks: Delay rigorous massage therapy until the infection has
 Neuraminidase - AKA Swine flu peaked. Afterwards, be aware that sinuses may be painful, and
 Ex: H2N2, H3Na = common human variants - Fast-moving pandemic in 2009 make appropriate accommodations. Working with a client who is
Complications - Targets younger adults, can be fatal just getting over a cold or flu may exacerbate symptoms for a day,
- Pneumonia, acute bronchitis Signs and Symptoms and then speed healing (this is purely anecdotal) – it is important
 Can be fatal - Subtle to fatal to warm of this possibility.
- Especially for high risk populations  Looks like a bad cold: Benefits: Gentle work during an infection may be soothing, and
 Children 2-5 years old o Respiratory irritation with headache and body aches sleep-promoting, if precautions protect the therapist from catching
 Those over 65 years old o Long-lasting high fever (may go over 102°) the cold. Afterwards, massage therapy may help with sinus pain
 Smokers o Possible vomiting, but not because of viral attack on GI and general recovery.
 Those with diabetes or immune suppression, tract
chronic lung or heart problems  No stomach flu
- Persistent, extreme symptoms suggest pneumonia
Pneumonia
Pneumonia
Definition Types of Pneumonia Treatment
- Inflammation of the lungs, usually from infection - Can be classified by… - depends on type of pneumonia
- Severity ranges from “bad cold” to death within 24 hours  Location  bacterial, mycoplasma respond to antibiotics
Demographics  Source of infection - cough suppressants are often discouraged
- Leading cause of death by infectious disease in US Location: Bronchopneumonia - rest, humidified air, fluids, supplement O2 if necessary
 Opportunistic infection, takes advantage of - Starts in bronchi, moves to lungs Medications
weakness - Patchy, not segregated - Antibiotics if necessary
- Hospitalized 5 days on average Location: Lobar pneumonia - Antivirals if necessary
- Mostly in people over 65 - Restricted to 1 lobe - NSAIDs
Etiology Location: Double pneumonia Massage Therapy Implications
- Gaseous exchange happens in alveoli - Affects both lungs Risks – pneumonia can be a serious infection, and a client who has
 Any obstruction (i.e., fluid, mucus in the alveoli) Source: Community-acquired pneumonia: it does not need to be any further challenged. Gentle supportive
prevent this - Most common massage may be helpful, if the therapist is safe from infection.
- Infection in alveoli can lead to - Bacterial, or a complication of flu Benefits – massage therapy may be helpful in the recovery process
 Abscesses Source: Nosocomial or hospital-acquired pneumonia after the acute phase of pneumonia has safely passed. A person
 Capillary damage - Develops within 48 hours of being in a healthcare setting with a history of pneumonia but no symptoms is a good candidate
 Bleeding into alveoli (leads to blood sputum) Aspiration pneumonia for massage therapy
- Scar tissue develops in lungs, between lungs and pleurae - Related to accidental inhalation of food or liquid Options – manual percussion on the thorax may help loosen sticky
- Pleural fluid can become infected - Danger for those with impaired swallow or cough reflex mucus, which can aid in recovery
- Causative agents: Signs and Symptoms
 Viruses – about half of all cases - Sudden or gradual onset
 Bacteria  Coughing
 Mycoplasma  High fever (up to 104°), chills, sweating, delirium
 Fungi  Chest pain
o Pneumocystis carinii/pneumocystis jiroveci  Cyanosis
- Prevention:  Thick sputum
 Annual flu vaccine help to prevent complications  Shortness of breath
from flu  Aches and pains
 Pneumovax against pneumococcus is  pleurisy
recommended for high-risk populations
Sinusitis / Chronic Rhinitis

- Start massage on sinuses, end on sinuses
- Prone presents with worsening symptoms
Sinusitis
Definition Types of Sinusitis Treatment
- Mucous membranes that line the sinuses become inflamed Non-infectious Sinusitis - Stay in humid, warm air
- Can be infectious or non-infectious - AKA: allergic rhinitis, hay fever - Increase fluid intake
Demographics - Inflammation of sinuses without infection - Saline wash
- Appears to be increasing  Lack of congestion, thin runny discharge - Antibiotics, if necessary (may be long-term)
 Indoor pollution, antibiotic resistance (?) - Long-term inflammation raises the risk of secondary sinus - Decongestants for short-term use
Etiology infection - Inhaled steroids
- Sinuses provide resonance for voice, lighten the weight of the Infectious Sinusitis - Balloon catheter, or surgery if necessary
head - Pathogenic invasion, inflammatory response at sinuses Medications
- Mucous membranes in sinuses are lined with cilia  Vicious circle: more inflammation causes more - Antibiotics, if necessary (with acidophilus to reduce the risk of
- If cilia are impaired (by irritants or local infection) the mucous infection, causes more inflammation yeast infection)
membranes become inflamed - Often a complication of cold or flu - Mucolytics
 Hollow areas fill with mucus, pus Signs and Symptoms - Antihistamines
- If cilia are function but mucous membranes respond to - Severe, pounding headache - Antifungal medication, if necessary
allergens, inflammation causes the production of gallon of thin,  Worse on bending over - Decongestants
runny mucus - Facial pain, especially near sinuses - Inhaled steroids
- Contributing factors:  Swelling, puffiness Massage Therapy Implications
 Viruses and/or bacteria - Coughing, sore throat, funny nose Risks – acute sinus infections contraindicate any massage therapy
o Complication of cold or flu - Bad breath, ear pain that might exacerbate symptoms. A person with a fever is better
 Fungi and bacteria - With infection: off delaying a session until the infection has passed. Be aware that
o Especially in immune-suppressed people  Fever, chills, thick, opaque mucus people with delicate sinuses may not be comfortable on a table
 Structural problems - With allergies: Benefits – If a client with inflamed sinuses can be comfortable,
o Deviated septum, polyps  Clear, thin mucous massage therapy may be soothing and relaxing, and may even be
 Environment irritants able to help open the sinuses for better drainage
o Cigarette smoke, pollen, dander Options – Therapists trained in lymphatic work may be able to help
 Other conditions symptoms due to allergic sinusitis
o Tooth infections, asthma
- Sinusitis is an acute or chronic inflammation of the paranasal sinuses

- Frontal, ethmoid, sphenoid and maxillary
- Lined with mucous membrane
- Appear during childhood and enlarge during adulthood
- Vary in size in the sphenoid bone
- Frontal sinuses drain into ducts and empty into the nasal cavity
- Ethmoidal sinuses vary in number and empty into the lateral portion of the nasal cavity
- Largest is the maxillary
 Present at birth and grow until 25
 Molars close
 Drains superiorly into the nasal cavity
 Must be horizontal to completely drain
- Acute sinusitis is inflammation and swelling of the sinus mucosa blocking discharge
- Chronic sinusitis occurs as a result of persistent/recurrent infection which may form polyps
 May lead to meningitis or brain abscess
- Causes of sinusitis are:
 Viral infection (from cold), bacterial infection (from molar removal or abscess) or increased pressure (airplane, diving forcing material to enter sinuses)
- Predisposing factors are:
 Deviation in nasal septum
 Dairy and wheat products
 Upper molar abscess
- Medically
 Analgesics and decongestants
 Prolonged medication use and OTC remedies can lead tissue damage and immunity
 Chronic cases surgery to drain sinus, remove mucous lining or repair the septum
- Symptoms Picture
 Acute sinusitis
 Pain, tenderness
 Infection above eyes, increases when bending over
 Maxillary is pain across cheeks
 Pain from sphenoidal and ethmoidal refers to side and back of cranium
 Head and toothache
 Sense of fullness and pressure
 Difficulty breathing through nose
 Fever
 Nasal discharge, clean and runny to yellow or green and thick
 Can spread to each other
 Chronic sinusitis
 Dull pain
 Discharge may stop entirely when blocked
- Assessment
 Palpation
 Frontal sinuses at medial angle of the superior orbital margin
 Maxillary under the zygomatic arch
 May feel tenderness, head
 Lymph nodes in the neck may be swollen
 Special Test
 Transillumination (light to those regions)
- Massage
 30 mins, avoid exhausting client
 Cleanliness
 Pre-treatment
 Hydrotherapy for 5 minutes with fascial steam
 Lots of disposable tissues and wastebasket
 Follow with compressions to decongest
 Positioning
 Prone draining of maxillary
 Side-lying maxillary
 Supine for the others
 With lymphatic drainage for chronic with increased duration
 If acute discontinue
 Prone for drainage, but may be painful
 Soothing techniques for the shoulders and upper thoracic
 TP in upper trapezius and temporal region, SCM and posterior neck muscles, mastication, scalp, and suboccipitals
 SCM eyes and ears
 Masseter to maxilla and frontal bone
 Temporalis to teeth and above eyes and ears
 Lateral pterygoid refers to zygoma and anterior ear
- Self-care
 Facial steam up to 5 a day and vaporizers
 Blow nose properly, one nostril at a time, don’t blow to hard (can lead to ears)
Tuberculosis
Tuberculosis
Definition Etiology: Phase 2 Signs and Symptoms
- “Condition of having tubercles (bumps)” - Active disease - Primary phase may not be noticed
- Pus-and-bacteria-filled bumps  5-10% of those exposed to TB develop active disease  Might look like flu
 Usually in lungs  Usually within a year, may be decades later - Active disease
 Can be elsewhere  Bacteria escape, spread further into lungs and elsewhere  Fever, sweating, weight loss, exhaustion
Demographics  Body tries to build bigger capsules  Chest pain, shortness of breath
- More common in third world countries o Scarring, pleurisy  Stubborn cough with pus-filled or blood phlegm
- Recent immigrants  Inside the capsules the bacteria are destroying tissue Treatment
- Native Americans o Filled with dead bacteria, pus, blood - Fresh air, rest, good nutrition
- People of color  New capsules erode into lung tissue, impede function - Antibiotics
- People in prisons o Cavitation  Much simpler to treat drug-susceptible TB than
- Homeless o Cough, bloody sputum other types
Etiology o Highly infectious  Requires up to 9 months of treatment
- Airborne bacterial infection - Major risk factor: exposure to someone with active disease  Side effects:
 Mycobacterium tuberculosis - Co-infection with HIV o Sensitivity to sunlight
- Waxy coat allows it to…  Makes transition to active disease more likely o Discolored tears, sweat, salvia
 Survive outside a host  Can interfere with accurate skin test (immune o Neuropathy
 Resist phagocytosis
- When a person with active disease coughs, bacteria are system suppression) o Joint pain
expelled and float in the air, waiting for a new host Types of Tuberculosis o Dizziness, tinnitus, etc.
Etiology: Primary Phase Drug-Susceptible Tuberculosis Medications
- A person inhales some floating bacteria into the lungs - Most common type, main focus of this discussion - Antibiotics
- Bacteria withstand normal phagocytosis, form colonies - Sensitive to 1st-line antibiotics Massage Therapy Implications
- The body encases them in fibrous cysts (tubercles) - Prognosis, if fully treated, is good Risks – TB is contagious through casual contact, although it usually
- Usually in the lungs, may happen at kidneys, spine, CNS Multidrug Resistant Tuberculosis (MDR-TB) takes prolonged exposure. Active, untreated TB contraindicates
- This is latent infection - Mutation occurs when someone doesn’t complete their massage therapy (or any public exposure). Be aware that clients
- After 10 weeks skin tests will be positive treatment who are taking medications for TB may have uncomfortable side
- Bacteria may stay encased for a lifetime – this is the case for - Someone who has MDR-TB can spread it effects that require some accommodations.
90% of all who are exposed - Bacteria are resistant to all 1st line antibiotics; requires longer, Benefits – a client who is treating TB and who has been declared
more risky treatment with drugs that have more side effects non-communicable is a good candidate for any massage therapy
SPINE = TB called Pott’s disease DON’T CONFUSE for Pott’s fracture Extensively Drug Resistant Tuberculosis (XDR-TB) that respects whatever challenges his or her treatment may
of the ankle - Resistant to almost all antibiotics present
- Most common in parts of Asia, Russia, and in HIV+ populations
in South Africa
Chronic Obstructive Pulmonary Disease

Chronic Bronchitis
Chronic Bronchitis
- Part of chronic obstructive pulmonary disease (COPD) - High risk of viral, bacterial respiratory infections
- Long-term irritation of bronchi and bronchioles  Mucus-filled bronchioles are a good growth medium
- Permanent, progressive, irreversible - Respiratory infections complicate to pneumonia
- Predecessors to emphysema - Progression to emphysema
Demographics - Right-sided heart failure
- COPD is a leading cause of death in the US Signs and Symptoms
 Chronic bronchitis and emphysema; statistics are not separated as - Slow onset
these often go hand-in-hand - Cough develops, is present most days for 3 months+
- Usually over 65 years old  Produces thick, clear sputum
- Men > women, but that number is approaching equivalence  This pattern persists for 2 years+
Etiology - Frequent throat-clearing, shortness of breath
- Long-term irritation to bronchiole tubes - Vulnerability to respiratory infection
 Cigarette smoke (direct or indirect) - Late stage:
 Air pollutants  Cyanosis, pulmonary edema, heart failure
 Industrial chemicals Treatment
- Inflammatory response at bronchiole linings - Aggressive treatment of even minor respiratory infections, as these can become life-threatening quickly
 Destroy elastin - Vaccinations against flu, pneumococcus
 Overgrowth of mucus-producing cells - Halt the progression to emphysema if possible, deal with symptoms
o More mucus  Quit smoking
o More resistance to air moving in and out  Avoid polluted air, other triggers
 Hyper-reactivity in bronchioles  Supplement oxygen if necessary
- When elastin breaks down…  Medications to improve lung function
 Act of exhalation is no longer passive: now it takes MUCH more Medications
energy to breathe - Bronchodilators
- When the bronchioles fill with mucus… - Inhaled and oral corticosteroids
 Act of inhalation is met with resistance too - Expectorants
- When the lungs don’t work well… - Antibiotics, if necessary
 The heart has to work harder to pump through the pulmonary Massage Therapy Implications
circuit Risks – some people with chronic bronchitis may not be comfortable lying flat on a table. The medications they use may
 More RBCs are produced to carry more O2 – blood gets thicker impact massage therapy decisions. Finally, even a mild cold virus can be life-threatening for a person with this condition,
 O2 levels in the blood drop so it is vital to be careful about the risk of respiratory illness.
o Acidosis, vasoconstriction in pulmonary arteries, heart has Benefits – gentle massage therapy can be helpful for a person with chronic bronchitis, with respect for possible frailty
to work even HARDER Options – address the muscles that control breathing for best efficiency and relief of fatigue
- Chronic bronchitis is a condition that results in the production of purulent sputum (phlegm) for at least three months in a row over 2 consecutive years
- More common in males
- Individuals 40+
- 10-25% of adults are affected with this disease
- Smokers and non-smokers
- 2 sources:
 Bronchial glands  enlargement
 Epithelial goblet cells which line the bronchial walls  increase in goblet cells
 Decrease in number of ciliated epithelial cells which remove mucus
- Results from chronic irritation leading to inflammation
- Leads to blockage of airways leads to insufficient oxygenation in alveoli
 Cyanosis (blush-ish tinge on skin and lips)
- Leads to general peripheral edema
- Results in decrease expiratory airflow rates and prolonged expiration
- May wheeze, productive coughing, dyspnea (SOB), and bouts of respiratory infection
- Leads to less tolerance for exercise and stress, even eating becomes exhausting
- Retains weight (emphysema people are thin)
- Those with cyanosis, edema and weight retention are called “blue bloater”
- OR “non-fighter” because they do not fight for air
- End of the fingers become bulbous or clubbed
- Can lead to pulmonary hypertension, right-sided heart failure (cor pulmonale) and death
- Chronic obstructive pulmonary disease (COPD) is a combination of chronic bronchitis and emphysema
 Occurs primarily in smokers
- Causes of chronic bronchitis are:
 Smoking
 Environmental factors
 Air pollution and occupational exposure to inhaled particles or fumes
- Breathing Muscles average person breathes 10-12 times per minute (upon activity can reach up to 50)
 Diaphragm
 External intercostal lift the ribs
 Scalenes elevate the 1st 2 ribs
 SCM lifts the sternum (only when head has proper posture or hyperextended)
 Sublcavius elevates the 1st rib
 Serratus posterior raises the 2nd through 5th rib
 Latissimus dorsi raises ribs 9-12
 Pectoralis major raises the sternum and 2 nd to 6th rib
 Pectoralis minor raises the 3-5 ribs
 ***trap does not have a direct involvement, but stresses, along with serratus anterior and pectoral muscles***
 Rectus abdominus, internal and external obliques and quadratus lumborum are recruited during coughing
- Effectiveness of Manual Therapy
 Joint manipulation, mobilizations and stretching
 Increases expiratory flow rates
 Postural drainage (table leaning), cough, tapotement, vibrations and shaking
 Relieve dyspnea and improve efficiency of ventilation and respiratory function
 Exercises: diaphragmatic breathing, segmental breathing and pursed-lip breathing
- Symptom Picture
 There is an increase in mucus production from the bronchial glands and an increase in the number of goblet cells due to chronic irritation
 The airways narrow due to chronic inflammation, thickening of the bronchial airways and accumulated mucus
 There is decrease mobility of the thoracic joints
 Respiratory infections may be present
 A chronic productive cough is present, which worsens in the morning and evening and in the winter months
 The cough begins slowly, worsening over weeks or months until it productive
 Mucus is thick
 Cyanosis occurs due to hypoxemia
 The finger ends are clubbed or bulbous
 The person tends to retain weight
 Peripheral edema results from venous stasis and right-sided heart failure
- Assessments
 Observation
 Head leans forward to assist breathing
 Muscle of respiration are hypertrophied
 Dyspnea (SOB) or tachypnea (rapid, shallow breathing)
 May be upper chest (apical)
 Barrel chest
 Hyperkyphosis, hyperlordosis or scoliosis may be present
 Pursed lip breathing
 Anxiety
 Cyanosis
 Nails or lips
 Clubbing of the fingers
 Weight retention
 Peripheral edema
 Palpation
 Muscles include: diaphragm, intercostals, scalenes, SCM, pec minor and major, and abdominals have increased tone, lats and costal
margins are tender
 TP likely
 Edema
 ROM
 AROM
 Thoracic, cervical spine and shoulder girdle reduced ranges
 Especially thoracic
 PROM
 Static and motion palpation reveal hypomobility
 Especially in thoracic
 ISO
 Shoulder girdle and abdominals present with weakness
 Special Tests
 Vocal fremitus and mediate percussion tests will be positive for congestion and help locate the affected areas
 Measurements of thoracic circumference at full inhalation and exhalation
 See magee: just do the nipple line (T4) 3.5-7cm difference
 Rib motion test is positive
 Levatores costarum test ???? WTF is this
 Anterior and lateral spinous challenges
 Check for hyperkyphosis
 Check for pec minor and major length
- Contraindications
 Do not exhaust the client with overtreatment or the prolonged application of painful techniques
 Joint play techniques for the ribs and rib springing are contraindicated with rib hypermobility and history of rib subluxation
 Postural drainage is contraindicated with severe hemoptysis (blood in mucus), severe pulmonary edema, congestive heart failure, pulmonary embolism, severe hypertension or hypotension, recent myocardial infarction and recent neurosurgery
 Do not use postural drainage directly after the C has eaten
 Tapotement is contraindicated over bony prominences, floating ribs and breast tissue
 The prolonged tapotement that accompanies postural drainage is contraindicated with chest-wall pain, unstable angina, anticoagulation therapy, osteoporosis, rib fracture, prolonged steroid therapy, hemoptysis, untreated lumb abscesses, pulmonary
embolism and open thoracic wounds or burns
 Thyme essential oil is contraindicated with pregnant clients or those with hypertension
 A client with cardiac or renal disorders should not increase the daily intake of water to thin mucus secretions
 Chronic airflow obstruction may lead to pulmonary hypertension and to right-sided heart failure
- Treatment
 Spread treatment over several appointments
 BP before and after the treatment with htn
 Positioning
 All can be used
 Chronic cases limits supine position to longer periods
 Favor prone
 Lying on affected side
 Bilateral R side
 Prone, towels under the shoulders if they are protracted
 Hydrotherapy
 Fascial steam for 5 minutes
 Pectoralis major muscles
 Thin secretions
 Encourage diaphragmatic breathing
 Reduce tone
 Reduce TP
 Reduce pain
 Increase local circulation to flush out metabolites
 Mobilize the thorax
 Diaphragmatic breathing segmental breathing
 Joint mobilization on the thorax
 Remove secretions
 Positioning is important >>>>>>
 Ask C what position is better?  some would prefer a chair
 Maintain position for 3-5 minutes or longer depending on tolerance of C
 Plastic lined wastebasket is needed
 Make a safe word or signal
 Tapotement is done at a slower rate (avoid bronchospasm)
 Rotate between superficial and deep tapotement techniques
 Vibrations can also be used
 Should wear gloves
 End with superficial effleurage and stroking
- Self-Care Goals
 Practice breathing exercises
 Pursed-lip breathing
 Productive coughing (lean forward on a table with arms over head)
 Combination for a productive coughing and diaphragmatic breathing is called forced expiratory technique
 Done 10-20 minutes, 2 times daily
 Huffing
 Thin secretions
 Mobilize the thorax
 Fascial steam/hot showers
 Drinking 6-8 glasses of water per day
 Stretch short muscle
 Reduce or eliminate perpetuating factors
 Encourage activity
 Stop smoking
 Pollutants removal
 45 minutes to 1 hour, once a week while coughing and SOB is present
 Ongoing condition
 Massage can reduce dyspnea, increase thoracic mobility and facilitate mucus expectoration
Emphysema
Emphysema
- Part of chronic obstructive pulmonary disease (COPD) with - Poor resistance to respiratory infections - Nicotine patches or gum for smoking cessation
chronic bronchitis - Ruptured bullae – lung collapse - Bronchodilators
- Emphysema means “inflated” - Right-sided heart failure - Inhaled or oral corticosteroids
 Alveoli merge into large sacs - Pulmonary embolism - Mucolytics, expectorants
- Progressive, permanent, irreversible Signs and Symptoms - Antibiotics if necessary
Demographics - Slow onset Massage Therapy Implications
- COPD is a leading cause of death in the US - Usually in people over 65, easy to miss early signs Risks – some people with emphysema may not be comfortable
- A factor in 125,000-135,000 death/year - Pain with breathing, shortness of breath lying flat on a table. The medications they use may impact massage
Etiology - Labored exhalation, “barrel chest” therapy decisions. Finally, even a mild cold virus can be life-
- Two main issues: - Wheezing, rales threatening for a person with this condition, so it is vital to be
 Exposure to cigarette smoke - Cough careful about the risk of respiratory illness
 Alpha-1 antitrypsin deficiency - Weight loss, exhaustion Benefits – gentle massage therapy can be helpful for a person with
- Alveoli no longer recoil at the end of inhalation Treatment emphysema, with respect for possible frailty
- They fill with mucus - Focus on stopping, slowing progression Options – address the muscles that control breathing for best
- Alveolar walls merge to form large bullae  Remove irritating stimuli efficiency and relief of fatigue
 Loss of surface area means less gaseous exchange  Medication to improve lung function
with capillaries  Vaccinations for flu, pneumococcus
- A person with emphysema must invest up to 50% of resting  Supplement oxygen as necessary
energy in breathing (normal is 5%)  Lung reduction surgery
- Impaired O2-CO2 turnover leads to hypoxia, which leads to…  Lung transplant surgery
 Thickened epithelial walls of alveoli; they become
less permeable
 Slowed respiration due to extra effort, hypoxia is
exacerbated
 Vascular spasm, which adds resistance to the
pulmonary circuit
- Emphysema is a disease that causes enlargement of air spaces distal to the terminal bronchioles and destruction of the alveolar walls
- Defined by the portion of the primary lobule (acinus) affected
- 2 most common forms are:
 Centrilobular (Centriacinar)
 Destroy the central portion of the acinus
 Most associated with smoking
 Abnormal, enlarged air spaces surround normal tissue
 Most in upper lobes
 Panlobular (Panacinar)
 Destroy the lobules uniformly throughout the lungs
 Inherited enzyme deficiency
 Paracicatrical
 Associated with previous lung pathology, ex. TB
 Enlarged air spaces are formed due to fibrosis and scarring
- The destruction of the alveolar wall leaves large air spaces, the largest called “bullae”
- Causes inefficient gas exchange due to reduced surface area
- Causes the elastic recoil of the lung to be lost, leading to collapse
- Leads to congestive heart failure and death
- 2/3rds men and 1/7th women
- Most common in smokers
- Causes of emphysema are:
 An overabundance of proteolytic enzymes
 Cause an inflammatory response that irritates
 Commonly cig smoke
 Basophils and neutrophils after inflammatory response necrose leaving the enzyme that eats lung tissue
 Inherited lack of proteolytic enzyme inhibitors
 Larger than normal air spaces
- Symptom Picture
 Dyspnea (SOB), and worsens
 Coughing, wheezing, prolonged expiration and physical inactivity leading to deconditioning
 Barrel chest
 Leans forward with arm rotation to increase respiration, but still little reserve
 Hypoxia, but maintains oxygen levels
 “pink puffer” or “fighter”
 Weight: thin
 Tachypnea (rapid, shallow breathing)
 Breathlessness when supine may indicated pulmonary or cardiac pathologies, poor left ventricle due to rush of blood returning to the heart
 Pulmonary hypertension  enlargement of right ventricle, right-sided heart failure (cor pulmonale) and death
Chronic Obstructive Pulmonary Disease

- Chronic Obstructive Pulmonary Disease
 Chronic obstructive pulmonary disease (COPD) describe a spectrum of diseases, most frequently some combination of emphysema and chronic bronchitis. Cystic fibrosis (CF) is also a COPD. Asthma, due to its episodic nature is not a classic COPD but
may be listed
 Smoker, pollution or hereditary
 20% smokers
 40-50
 Progress to respiratory failure and cor pulmonale
 Hard to differentiate between chronic asthma in adults
 Cystic fibrosis is a genetic disorder of the apocrine glands
 Increase size and number of bronchial mucous glands
 Increased salivary, sweat and pancreatic glands
 Bronchial mucus glands produce large amounts of mucus that are sticky
 Results in airway obstruction
 Coughing is less productive
 Leads to 2nd infections
 Bronchiectasis is an irreversible dilation and thickening of the bronchi
 Hyperinflation of the lungs results in increased secretions
 Atelectasis, or loss of lung inflation when obstruction is complete
 Leads to death
 Managed through diet, medication, pancreatic enzyme replacement and chest physical therapy
 Is thin, barrel chested and lethargic due to doubts of coughing, dyspnea and hypoxia
- Assessments
 Observation
 Elevated shoulders
 Barrel chest
 Horizontal ribs
 Exhalation is prolonged
 Breathless
 Lean on elbow and shoulders
 Pursed-lip breathing
 Respiration muscle prominent
 Looks fatigued
 Skin may be rosy or pink
 Finger tips clubbed or enlarged
 Palpation
 Thoracic rigidity, hypertonic (diaphragm, intercostals, scalenes and SCM)
 ROM and Special Tests
 Same as chronic bronchitis
- Contraindications
 Do not exhaust the client with overtreatment or use of prolonged painful techniques. This is increasingly important as the severity of the emphysema increases
 Avoid placing the client with severe emphysema in a supine or prone position
 Postural drainage is contraindicated with severe hemoptysis (blood in mucus), severe pulmonary edema, congestive heart failure, pulmonary embolism, severe hypertension or hypotension, positional dyspnea in the head-down position, recent myocardial
infarction and recent neurosurgery
 Do not use postural drainage directly after the client has eaten
 The prolonged tapotement that accompanies postural drainage is contraindicated with chest-wall pain, unstable angina, anticoagulation therapy, osteoporosis, rib fracture, prolonged steroid therapy, hemoptysis, untreated lung abscesses, pulmonary
 Joint play techniques for the ribs and rib springing are contraindicated with rib hypermobility and a history of rib subluxation
 A client with cardiac or renal disorders should not increase the daily intake of water as is sometimes recommended as self-care
 Chronic airflow obstruction may lead to pulmonary hypertension and right-sided heart failure or cor pulmonale, necessitating treatment modifications
- Massage
 Take severity into account—GO SLOW! Light, soothing and repetitive
 Severe relaxation and improve breathing patterns
 Reduce tx to 30 mins
 Be aware of oxygen tank
 Monitor BP before and after treatment in the case of htn
 Positioning
 Semi-supine position—pillow under head, arms and trunk
 Severe side-lying, seated or leaning forward
 Hydrotherapy
 Fascial steam to secrete mucus
 Primary goals:
 Reduce pain—reduce sympathetic nervous system firing
 Promote relaxation of respiration muscles
 Mobilize thorax—everywhere may be treatment as well
 Reduce stress
 Decrease fascial restrictions
 Decrease TP
 Postural drainage
- Self-care
 Decreasing or moderating the severity and frequency of symptoms
 Pursed-lip breathing
 Productive coughing
 Get important from physician for exercises and hydrotherapy
 Sitting with arms forward and head down
 Stop smoking
Other Respiratory Disorders

Asthma
Asthma aka panting

Definition Types of Asthma Treatment
- Airway disorder Bronchial Asthma - Limit exposure to triggers
 Triggered by allergens or pollutants - Most typical form - Medication to improve lung function, quell histamine release
 Triggered by emotional stress - Tight bronchioles and excess mucus production - Consider allergic desensitization
Demographics Exercise-Induced Asthma Medications
- More common, more serious among African Americans - AKA exercise-induced bronchoconstriction - Bronchodilators
compared to other groups - Occurs with physical exertion - Inhaled or oral corticosteroids
Etiology  May be delayed for several hours - Inhalants may be fast-acting or slow-acting
- Bronchioles are hypersensitive to debris - May be related to insufficient conditioning of incoming air - Antihistamines
- Ongoing inflammation Silent Asthma Massage Therapy Implications
- Any trigger lead to - No warming symptoms Risks – Be aware of hypersensitivity issues, and create an
 Swelling in the bronchioles - Sudden onset of being dangerously short of breath environment that is free from respiratory stimuli. Offer a
 Severe bronchospasm Cough Variant Asthma hypoallergenic lubricant. Some medications may have implications
 Excessive mucus production - Primary symptom is coughing for massage therapy choices
- Common triggers include… - Episodes may occur in the nighttime Benefits: Massage therapy can be soothing for a person who lives
 Pet-related allergens Signs and Symptoms in anxiety about being able to breathe
 Cigarette smoke - Dyspnea, wheezing Options – address the muscles that control breathing for best
 Dust mites - Coughing (dry or productive) efficiency and relief of fatigue
 Cockroach wastes - Easier to inhale than to exhale
 Gastroesophageal reflux disorder - Panicky reaction
Asthma Ratings  Sweating, increased heart rate, anxiety, cyanosis
- Mild, intermittent
 Less than 2 times a week, little impact on activity
- Mild, persistent
 More than 2 times a week, and at night; activities
may be affected
- Moderate, persistent
 Episodes every day, at night at least 1 time a week
- Severe, persistent
 Attacks most days and nights; activity is severely
limited
- Asthma is a chronic inflammatory disorder characterized by bronchospasm (narrowing of the airways in the lungs), which is reversible over time either spontaneously or following treatment
- Aka panting
- Is straitness, compression or constriction of the bronchi
- 5% of the world
- Recent increase in mortality rate
- Most have mild symptoms
- Appear in childhood or in middle
 10 years of age
 Remission is common
- Boy 3:2 to girls
- Those over 40 increase
 Persistent and remission less frequent
- Ratio of asthma in adults in the genders
 Women are less likely to have remission
- Histamines are released from mast cells in the airways and inflammatory process leads to edema (from eosinophils) and thickening of the bronchial walls
 Longer term the goblet cells enlarge and the bronchial smooth muscles may become thickened
- Normal mucus production is sticky and inhibits ciliary actions, leading to return and plug formation/air trapping leading to increased lung volume
- Tested through the vagus nerve
- Causes of asthma are:
 Underlying airway inflammation and abnormal bronchospasm response to triggers
 Urban areas, environmental factors override genetic factors
 Allergens, air pollution or changes in diet
 Dust mites aka dermatophagoides pteronyssinus
 Cigarette smoking
 Occupational factors
 5%
 Chemicals such as: isocyanates, epoxy resins, adhesives, polyurethane foam, paint and plastics, wood, grain and flours
 Food allergies
 Exercise-induced asthma
 Cooling and drying effect of inhaled air
 Atopy is inherited allergy, but not specific
 Hay fever and eczema
- Types of Asthma
 Extrinsic
 Outside the body
 Weather changes
 Intrinsic
 Inside body
 Genetic
 Can be either or
- Symptom Picture
 Symptoms range
 Severity of asthma:
 Mild asthma
 Occasional wheezing or a cough that does not impair activity
 Sensitivity includes allergens and cold airs
 2-3 times a week
 Moderate asthma
 Daily symptoms
 Occasional nocturnal symptoms
 Avoidance of exercise
 Severe asthma
 Daily wheezing, severe nocturnal symptoms, absence from work or school, poor quality of life and occasional hospitalization
 Nocturnal worst between 2-4am
 Cough 5-10 mins after exercise begins
 Maximal symptoms occur 3-15 minutes after exercise ceases
 Airway obstruction over time becomes irreversible
 Poorly controlled asthma
 May suffer from emphysema or chronic bronchitis
 Chronic uncontrolled asthma
 Air trapping leads to hyperinflation and changes in thorax
 May lead to pulmonary hypertension and right-sided heart failure resulting from primary lung disease (cor pulmonale)
 Children
 Paroxysmal coughing, especially at night
 Chest tightness, wheezing and breathlessness to mid-childhood
 Acute asthma attack
 Sleep disturbance
 Prolonged airway obstruction
 Exhalation decreases
 Unproductive coughing
 Wheezing is audible
 Anxious and sweating
 Person sits upright
 Dyspnea (SOB), distress, labored breathing, tachypnea (rapid, shallow breathing)
 May lead to medical emergency
 25 breaths per minute, HR is 110
 Cyanosis, exhaustion, confusion and coma
 Aka status asthmaticus / life threatening acute severe asthma
 Lasts 24 hours
 Leads to dehydration
- Assessments
 Observation
 Respiration muscle have increased tone
 Dyspnea or tachypnea
 Apical (using chest only)
 Hyperkyphosis, forward head posture or scoliosis
 Barrel chest
 Poorly controlled asthma
 During: seated, leaned forward, shoulder girdle stabled, exhalation rapid, labored and incomplete
 Possible anxiety
 Palpation
 Respiratory muscles
 TP
 ROM and Special Tests
 Same as the other respiratory conditions
- Contraindications
 Determine C asthma triggers
 Cleanliness of room and removal of sensitive products
 Do not exhaust the client with overtreatment or prolonged painful techniques
 Avoid direct compression on the xiphoid process and the floating ribs
 Joint play techniques for the ribs and rib springing are contraindicated with rib hypermobility and a history of rib subluxation
 Postural drainage is contraindicated with severe hemoptysis (blood in mucus), severe pulmonary edema, congestive heart failure, pulmonary embolism, severe hypertension or hypotension, recent myocardial infarction and recent neurosurgery
 Do not use postural drainage if the client has recently eaten
 The prolonged tapotement that accompanies postural drainage is contraindicated with chest-wall pain, unstable angina, anticoagulation therapy, osteoporosis, rib fracture, prolonged steroid therapy, bronchospasm, untreated lung abscesses, pulmonary
 Bronchodilator medication taken recently may indicated treatment modifications. Long-term steroid use may lead to osteoporosis
 Chronic air-flow obstruction may lead to pulmonary hypertension and, in occasional cases, to right-sided heart failure or cor pulmonale, necessitating treatment modifications
 Avoid an increase in daily water intake self-care if client has cardiac or renal disorders
- Treatment Goals
 Between attacks
 Ask where their inhaler is
 Severe patient may need it before tapotement
 Positioning
 Any position
 Severity reduce supine position to side-lying
 Prone better
 Hydrotherapy
 Facial steam 5 minutes prior to the massage to help thin mucus
 Reduce stress
 Mobilize the thoracic
 Decrease secretions
 General Treatment
 Prone position, with pillow under C’s abdomen and ankles and towels under shoulder if protracted
 Hydrotherapy
 Heat over the lower posterior intercostals before treating fascia
 Heat may be applied to pectoral muscles
 Specific Treatment
 ****
 Tight levator costarum
 Short
► From the TVPs to the next inferior rib
► Found from C7 to rib 1 to T11 and rib 12
 Long
► From T7 TVPs and rib 9 through T10 and rib 12
 Abdominal Skin Rolling
 Decrease pain—decrease sympathetic nervous system firing
 Reduce fascial restriction
 Reduce hypertonicity
 Reduce trigger points
 Encourage circulation in overused structures
 Mobilize the thorax
 Reduce fascial restrictions
 Increase local circulation to flush out metabolites
 Stretch shortened muscles
- Self-Care Goals
 Control acute attacks
 Reduce or eliminate triggers
 Breathing exercises
 Pursed-lip and productive coughing
 Stretch short muscles
 Teach self-massage
 Mobilize thorax
 Thin secretions
 1 hour once a week until posture and breathing improve
 Increased for stress and maintenance of thoracic and cervical mobility
Cystic Fibrosis
Cystic Fibrosis
Definition Etiology: CF in the Integumentary System Treatment
- Autosomal recessive genetic disorder - Thick, salt perspiration - Focuses on symptoms and complications
 1 faulty gene is inherited - Risk of heat stroke, salt depletion  Devices to reduce lung congestion
- Affects all exocrine glands Etiology: CF in the Reproductive System  Eating adjustments and supplements
 Thick, sticky secretions in all systems - Men with CF are almost always sterile  Exercise for general stamina and lung resilience
 Respiratory system are most impacted - Women with CF can have successful pregnancies  Bronchodilators
Demographics Signs and Symptoms  Mucolytics
- Most common life-limiting genetic disorder in US - Depends on system affected, as discussed  Antibiotics as needed
- About 10 million may carry the gene; many don’t know - Respiratory symptoms include…  Medications to manage complications, as needed
- Median life expectancy is about 37 years  Dry or productive cough  Lung transplant (high rejection rate)
 Men live longer  Dyspnea, wheezing Medications
Etiology: CF in the Respiratory Tract  Chest pain - Inhaled bronchodilators
- CF is the result of many possible mutations; all lead to…  Cyanosis - Inhaled mucolytics, saline
 Thick, sticky secretions in exocrine glands, especially  Hemoptysis - Inhaled and oral antibiotics
the respiratory tract  Clubbing of fingers (result of long-term O2 deprivation) - Anti-inflammatories
- Mucus is difficult to dislodge from lungs - Massage Therapy Implications
 Bacteria, other pathogens can grow in it Risks – the main concern about massage therapy for client with CF
o Pseudomonas aeruginosa is most difficult is the risk of respiratory infection. If that is managed, massage
 Immune system response makes it worse therapy within the client’s capacity for adaption is safe.
- Also causes nasal polyps, rhinitis Benefits – many CF patients undergo aggressive therapy to
- Resistance in lungs can cause right-sided heart failure dislodge mucus in the lungs, and they are recommended to
- Intestinal obstruction in newborn exercise. If massage therapy fits within these parameters for
- Poor absorption of nutrients: challenge, then it is probably safe and may help with fatigue,
 Failure to thrive, bulky stools anxiety, depression, and other consequences of living with a
 osteoporosis complicated condition.
- Accessory organ repercussions Research – massage therapy may be helpful for pain, easy of
 Gallstones, liver congestion, cirrhosis, diabetes, ulcers, breathing, and general quality of life for both children and adults
pancreatitis with CF.
Laryngeal Cancer
Laryngeal Cancer
- Development of malignant growths on or around the larynx - Chronic cough
Demographics - Hoarseness, sore throat
- Usually in mature people with history of tobacco use - Sense of something being “stuck” in the throat
- Men > women, 4:1 - Bad breath
Etiology - Problems breathing
- Larynx is vital for speech, swallowing, protecting the respiratory tract, breath control - Ear ache
 Risk of aspiration pneumonia when the larynx is compromised Treatment
- Larynx can develop polyps, nodules, tumors - Aggressive treatment with the priority of maintaining a healthy swallow reflex
- Cancerous tumors usually begin in squamous lining of the glottis, spreads to…  Radiation
 Tongue; cervical lymph nodes; lungs  Chemotherapy
- Risk factors  Surgery
 Any tobacco use Medications
 Excessive alcohol - Chemotherapeutic drugs
 Age & Gender - Post-surgery analgesics
 Exposure to human papilloma virus Massage Therapy Implications
 Poor dental hygiene Risks: Be aware of risks related to the cancer and caner treatments. Radiation, chemotherapy, surgery, and other
 Deficient vitamin A, beta-carotene interventions require adaptation and communication with the client’s health care team
 History of gastroesophageal reflux disorder Benefits: Massage therapy can help with the pain, anxiety, depression, and many other problems that accompany
 History of radiation to the neck the challenges of dealing with laryngeal cancer
 Exposure to nickel, sulfuric acid, asbestos Options: People undergoing treatment for laryngeal cancer may have a temporary stoma placed in their neck. This
and any other equipment that may be vulnerable to disruption must be accommodated.
Lung Cancer
Lung Cancer
Definition Risk Factors Signs and Symptoms
- Growth of malignant cells in the lungs - Inherited predisposition - Early:
- Eventually they form tumors - History of…  Smoker’s cough
 Can spread before tumors are detectable  Tobacco use, exposure to tobacco smoke  Bloody phlegm
- Epithelial cancer where tissue is repeatedly irritated and  Radiation to the chest  Chest pain
damaged  Tuberculosis  Wheezing, shortness of breath
Demographics  Chronic obstructive pulmonary disease - Later:
- #1 cause of death by cancer  Severe pneumonia  Signs of thoracic outlet syndrome
 More than breast, prostate and colorectal cancer Types of Lung Cancer  Superior vena cava syndrome
- 5-year survival rate is low (about 17% of diagnosed people) Small Cell Lung Cancer  Hoarseness
- Best prognosis when found before metastasis – only happens - AKA: oat cell carcinoma  Diaphragm paralysis
in 15% of cases - 20% of all diagnoses Treatment
Etiology - Grows fast, spreads quickly, usually inoperable - Often not treatable
- Cigarette, pipe, cigar smoke lead to 85-90% of all cases Non-Small Cell Lung Cancer - Surgery
- Other causes: exposure to… - Several subtypes - Radiation
 Radon - Up to 85% of all diagnoses - Chemotherapy
 Asbestos - Most grow more slowly than small cell lung cancer - Targeted therapies
 Uranium - Subtle symptoms; rarely caught before metastasis Medications
 Arsenic Other Types of Lung Malignancies - Chemotherapeutic drugs
 Air pollution - Carcinoid tumors - Targeted therapies
- These are more potent carcinogens when combined with - Adenoid cystic carcinoma - Medication to lessen chemotherapy side effects
tobacco use - Sarcomas Massage Therapy Implications
- After a long history of damage and repair… - Mesothelioma Risks - a client with lung cancer is likely either to be at the end of
 Orderly pattern of replication is disrupted life or undergoing aggressive treatment. Either way, this person is
 Abnormal cells accumulate likely to need care for fragility, medication side effects, bone
 Rich supply of blood and lymph vessels strength, major organ involvement, etc.
o Fast growth Benefits – massage therapy can be supportive for pain, sleep,
o Easy metastasis anxiety, depression, and other problems – all of which can make
o Able to suppress immune system response cancer harder to treat
- Rarely found before metastasis Research – Massage therapy is a popular choice for people with
 Goes to: lymph nodes in mediastinum; liver; bone; lung cancer for general support.
adrenal glands; brain
Digestive System Conditions
Disorders of the Upper Gastrointestinal Tract
Celiac Disease
Celiac Disease
- Condition in which intestinal villi are destroyed as part of an - In children: delayed growth development - Avoid gluten in any form
inflammatory reaction in the presence of gluten - Anemia, folic acid deficiency, risk of miscarriage, birth defects Medications
- AKA in growing fetus - Short-term steroids if necessary
 Celiac sprue - Osteomalacia, osteoporosis - Vitamin and mineral supplements as necessary
 Nontropical sprue - CNS problems - Topical medications for dermatitis herpetiformis
 Gluten-sensitive enteropathy  Behavior changes Massage Therapy Implications
Demographics  Irritability Risks: Watch for abdominal pain, and be sensitive to this
- Best estimate: about 2 million people  Peripheral neuropathy possibility; people with celiac may be also prone to skin rashes that
 Most undiagnosed  Seizures locally contraindicate massage therapy.
- Most common in non-Hispanic whites - Risk of adenocarcinoma, lymphoma Benefits: A clients with successfully managed celiac disease can
Etiology Signs and Symptoms enjoy all the benefits of massage therapy
- Gluten is a group of proteins in many grains - Related to malabsorption of nutrients Options: Some people with celiac disease are also hypersensitive to
 Breaks down into gliadin  Pain, discomfort in GI tract topical exposure to gluten or gliadin – these can sometimes be
 Gliadin triggers inflammatory reaction that destroys  Gas, bloating, diarrhea found in lotions or lubricants. Be sure to use a hypoallergenic oil or
villi in patches through the small intestines  High-volume stools lotion for clients with this problem.
- Without villi, access to all nutrients is lost  Weight loss
- Celiac may be related to other autoimmune diseases  Anemia
- Age at onset varies  Behavioral changes, depression, irritability
- Sometimes seen with painful rash: dermatitis herpetiformis  Cramps
 Weakness, poor stamina
 Several others…
- Can look like and/or be comorbid with irritable bowel
syndrome
Pathophysiology
- Celiac disease, also known as celiac sprue and gluten- sensitive enteropathy, is an immune-mediated disorder triggered by ingestion of the gluten-containing grains (wheat, barley, and rye)
- Until recently, celiac disease was considered to be a rare malabsorption syndrome that manifested during early childhood, but today is known to be one of the most common genetic diseases, with a
mean prevalence of 1% in the general population
- The disease is recognized not only in Europe and in countries populated by persons of European ancestry, but also in the Middle East, Asia, South America and North Africa
- One of the most common genetic diseases
 Affected share the MHCCII allele
- T-cell mediated reaction of gluten component
- Antibodies  inflammatory reaction  loss of small intestine villi  malabsorption
- Primary Treatment of Celiac Disease
- The primary treatment of celiac disease consists of removal of gluten and related proteins form the diet
- Gluten is the primary protein in wheat, barley, and rye
- Oat products, which are nontoxic, may be contaminated with wheat during processing
- Many gluten-free types of bread, cereals, cookies, and other products are available
- Meats, vegetables, fruits, and dairy products are free of gluten as long as they are not contaminated during processing
- Complete exclusion of dietary gluten generally results in rapid and complete healing of the intestinal mucosa
Esophageal Cancer
Esophageal Cancer
- Development of malignant cells in the esophagus - Hard to find early (leads to high mortality rate)
 Proximal  Dysphagia
 Distal  A sense of food getting stuck
Demographics  Pain with swallowing
- Worldwide: squamous cell esophageal cancer is most common  Unexplained weight loss
- US: adenocarcinoma of the esophagus is most common  Chronic cough
 One of few cancers that is increasing in incidence  Hoarseness
- Men > women, 4:1  Hiccups (phrenic nerve irritation)
Etiology  Other signs that suggest metastasis:
- Malignant cells in the upper/middle section = squamous cell  Deep pain
carcinoma of the esophagus  Fever, lung infection from fistula into the lungs
 Often related to smoking and alcohol use Treatment
- Malignant cells at the distal end = glandular cancer - Could include…
(adenocarcinoma)  Surgery
 Often a complication of GERD, Barrett esophagus  Chemotherapy
- Metastasis is easy  Radiation therapy
 No serous membrane, close contact with other organs,  Photodynamic therapy (drugs that are activated by exposure to light)
especially - Recovery can be challenging because it is difficult to take in nutrition
 Trachea Medications
 Diaphragm - Chemotherapeutic agents
 Aorta - Photodynamic therapy
 Vena cava Massage Therapy Implications
 Laryngeal nerve Risks: Make adjustments according to the client’s general resilience or fragility, treatment options, and side effects or complications
 Generous lymphatic supply Benefits: Massage therapy has been seen to help with pain, sleep, appetite, anxiety, depression, and other challenges that may affect
 Can also spread through bloodstream people with esophageal cancer.
Pathophysiology
- Cancer of the esophagus is a relatively uncommon form of cancer that is commonly linked to gastroesophageal reflux and Barrett esophagus (adenocarcinoma) or alcohol and tobacco use (squamous
cell carcinoma)
Barrett’s esophagus – a pathological change in the epithelium of the esophagus from nonkeratinized stratified squamous epithelium to columnar epithelium so that the lining resembles that of the stomach
or small intestine due to long-term exposure of the esophagus to stomach acid; increases the risk of developing cancer of the esophagus.
Gastroenteritis
Gastroenteritis
- Inflammation of the GI tract - Pathogens damage the intestines, lead to symptoms - Difficult to treat
 Usually stomach or small intestine  Produce toxins that damage cells - Prevent through hygiene, food safety
- Result of infection  Directly attack cells - Promote hydration
 Bacteria  Exacerbated by poor motility - Anti-diarrhea medications are sometimes discouraged
 Virus - When GI tract is damaged, absorption of nutrients, water is (may prolong infection)
 Parasite impaired Medications
Demographics  Dehydration, electrolyte loss through vomiting, diarrhea - Vaccine for rotovirus
- Most common cause = norovirus - Possible causes: - Antibiotics for bacterial infections
 No permanent immunity; multiple infections are possible  Viruses – high communicable, can be epidemic - Anti-emetics to control nausea, vomiting
- Bacterial gastroenteritis also common  Norwalk/noroviruses Massage Therapy Implications
 Clostridium difficile (C-diff) is common in health care settings  Rotavirus Risks: Client is unlikely to be comfortable, and cross-
- Worldwide, a leading cause of death for infants, young children  Hepatitis A, B, C contamination happens easily; it is best to delay massage
 Bacterial gastroenteritis kills mostly elderly  Enteroviruses therapy appointments until this infection has subsided
Complications  Bacteria Benefits: Digestive irritation that is unrelated to infection or
- Dehydration  Salmonella organic disease may respond well to massage therapy.
 Can be fatal  Shigella Someone who has recovered from an intestinal infection is
 Sunken eyes  Campylobacter a good candidate for massage therapy.
 Lack of urination/dark urine  E. coli
 Skin tinting  Often food poisoning, can be other
- Other problems:  C-diff is especially dangerous
 Guillain-Barre syndrome  Parasites
 Meningitis  Giardia
 Blood poisoning  Cryptosporidium
 Renal failure  Entamoeba histolytica
Signs and Symptoms  Others
- Nausea  Fungal infections (candidiasis)
- Vomiting  Toxins
- Diarrhea  Allergies
- Also  Medications
 Bloating  Other conditions
 Cramps - Highly communicable
 Gas  Oral-fecal contamination
 Mucus, blood in stools  Contaminated water, ice
Wiley
Gastroenteritis – inflammation of the lining of the stomach and intestine (especially the small intestine). It is usually caused by a viral or bacterial infection that may be acquired by contaminated food or
water or by people in close contact. Symptoms include diarrhea, vomiting, fever, loss of appetite, cramps, and abdominal discomfort.
Gastroesophageal Reflex Disorder
Gastroesophageal Reflex Disorder (GERD)

- Damage to the lining of the esophagus - Respiratory injury - Antacids
 From chronic exposure to digestive juices form the - Decay of tooth enamel - H2 blockers
stomach - Esophageal ulcers - Proton pump inhibitors
Demographics - Stricture - Coating agents for the stomach
- Most people experience reflex at some point - Barrett esophagus - Promotility agents
- Up to 10% have it once a week or more  Cells mutate to look like stomach lining Massage Therapy Implications
- Frequency of symptoms is a predictor for complications  Precancerous for esophageal cancer Risks: It is important not to exacerbate symptoms; some clients
Etiology Signs and Symptoms may not be able to lie flat, or may need to schedule appointments
- 4 factors combine: - Produced by action of gastric juice on esophageal lining around their meal schedule
 Lower esophageal sphincter (LES) is too relaxed  Bitter taste Benefits: Clients who successfully treat GERD can enjoy all the
 LES doesn’t separate food between esophagus and  Feeling of regurgitation benefits of massage therapy, although work on the abdomen may
stomach  Gas, indigestion, bloating have to be gentler than for some others
 Esophageal hiatus (hole in the diaphragm) traps a  Chest pain (can look like heart attack, angina) Options: Some clients with GERD may prefer to use a recliner or
portion of the stomach  Trouble swallowing massage chair to receive massage therapy
 Stomach is slow to empty, leading to backpressure at  Coughing, wheezing, hemoptysis Research: Massage therapy for infants with GERD done by parents
the LES Treatment can help to strengthen the parent-child bond.
- These allow stomach contents and HCl to enter and damage - Management and repair
the esophagus  Management:
- Risk Factors:  Lose weight, eat smaller portions
 Pregnancy  Don’t lie flat within 2 hours after a meal
 Obesity  Avoid caffeine, alcohol, nicotine, trigger foods
 Smoking  Loosen clothing at waist
 Diet high in fatty, spicy foods  Heating pad on abdomen
 Caffeine, alcohol use  Antacids
 Connective tissue disease, i.e., lupus, scleroderma  Repair:
 Hiatal hernia  Medication to block acid production in stomach
 Underlying disease that interferes with digestive  Medication to improve stomach motility
motility  Surgery to reinforce the LES, repair hiatal hernia
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- Gastroesophageal Reflex Disease (GERD)
 When the lower esophageal sphincter fails to close after food enters allowing hydrochloric acid (HCl) reflex (back up) into the inferior portion of the esophagus irritating it bringing about the
heartburn sensation
 Alcohol and smoking relaxes the sphincter, worsening the problem
 Irritants are coffee, chocolate, tomatoes, fatty foods, organ juice, peppermint, spearmint, and onions
 Treatment involves OTC histamine-2 (H2) blockers such as Tagamet HB or Pepcid AC 30 to 60 mins before eating to block acid secretion and neutralize acid with antacids such as Tums or Maalox
 Symptoms less likely with small portions and doesn’t lie down after a meal
 May be associated with cancer of the esophagus
Pathophysiology
- Gastroesophageal reflex refers to the backward movement of gastric contents into the esophagus, a condition that causes heartburn
- Persistent reflex of gastric contents into the esophagus can result in a condition called gastroesophageal reflex disease (GERD)
- Complications of GERD, which result from erosion and/or irritation of the mucosal surface of the esophagus, include esophagitis, strictures of the esophagus, and Barrett esophagus
- Gastroesophageal reflex is a common problem in infants and children
- Symptoms are typically mild and abate in most children by 2 years of age
- However, some infants and small children have significant reflex that interferes with feeding, causes esophagitis, and results in respiratory symptoms and other complications
- Reflex versus GERD
 Lower esophageal sphincter is weak/incompetent
 Refluxate  esophageal mucosa injury
 Treat with antacids, H2-receptor antagonists, proton pump inhibitors
 Can lead to Barrett esophagus  adenocarcinoma
Peptic Ulcers
Peptic Ulcer
Definition Stress and Ulcers Complications
- Any ulcer: - Population with highest stress jobs doesn’t have the highest - Can erode into capillaries, cause bleeding into stomach,
 Progressive tissue damage due to irritation and failure incidence of ulcer anemia
to heal  Other factors must play - Larger blood vessel damage can lead to hemorrhage and shock
- Peptic ulcer: - Aggressive vs. defensive mechanisms in stomach - Can perforate the stomach or duodenum, leading to peritonitis
 Same process at inner surface of the stomach,  Aggressive - Increases risk of stomach cancer, lymphoma
duodenum  Production of acid, pepsin Signs and Symptoms
Demographics  Defensive - Gnawing, burning pain in chest, abdomen
- About 10% have an ulcer at some point  Blood supply for cell regeneration, mucus - Lasts 30 minutes to 3 hours
- H. pylori is often a factor production - Can change with food (become better or worse)
 Not definitive; this pathogen can be present and never  Mucus protects was from acid, pepsin - Pain is relieved with antacids, more food
causes an ulcer  Acidity is neutralized in duodenum by pancreatic - Nausea, vomiting, loss of appetite, anemia
Etiology secretions Treatment
- Sore in esophagus, stomach, small intestine are peptic ulcers - Aggressive, defensive mechanisms should stay in balance - Antibiotics
(pepsin contributes to damage) - Stress sympathetic reactions shut down digestive system - Bismuth
- Used to be assumed they were related to… activity - Medications that block histamine release
 Stress  Lack of blood flow means less mucus AND less acid (so - Medications that block acid production
 Spicy, acidic food far, so good) - Suspend the use or irritating anti-inflammatories
- Now known to be multifactorial - Relief from stress: stomach activity and secretions recover - Surgical correction
 Fluctuation in stress  Acid, pepsin rebound faster than protective mucus Medications
 Bacterial infection - Fluctuations between sympathetic/parasympathetic responses - Antibiotics
 Medications may contributes to imbalances - Bismuth
Helicobacter Pylori and Ulcers Anti-inflammatories and Ulcers - H2 blockers
- H. pylori isolated in 1984, demonstrated to contribute to many - NSAIDs inhibit the cyclooxygenase-1 pathway - Proton pump inhibitors
peptic ulcers  Impedes the production of prostaglandins Massage Therapy Implications
 Bacillus with 2 flagella  This is anti-inflammatory, but it also impedes the Risks: Clients who have ulcers may need to make scheduling
 Allow it to survive in acidic environment, burrow down production of protective mucus in the stomach choices around their eating times, to avoid pain by lying flat on a
into stomach lining  Inhibits production of bicarbonate in pancreas table. Be prepared to offer massage therapy using a recliner or
 Stomach acid isn’t neutralized, duodenum is massage chair if necessary
vulnerable to ulcers Benefits: Massage therapy has no direct impact on ulcer, but
general relaxation may be helpful
Research: It is possible that massage and exercise may help to
promote ulcer healing, but the research has not been replicated.
Wiley
 peptic ulcer disease – ulcers that develop in areas of the GI tract exposed to acidic gastric juice.
 Most common complication is bleeding, which can lead to anemia.
 In acute cases, can lead to shock and death
 3 distinct causes are recognized
1. The bacterium H Pylori. Most common cause of PUD.
2. NSAIDs
3. Hypersecretion of HCl, as occurs in Zollinger-Ellison syndrome, a gastrin-producing tumor usually of the pancreas.
 Treatment – avoid cigarettes, alcohol, caffeine, NSAIDs. If caused by H. Pylori, treatment with antibiotics. Tums or Maalox to temporarily buffer gastric acid. H2 blockers or proton pump
inhibitors to block secretion of H+ from parietal cells if caused by hypersecretion of HCl.
Pathophysiology
- Peptic ulcer disease occurs in areas of the upper gastrointestinal tract that are exposed to acid-pepsin secretions, most commonly the duodenum and stomach
 The most common complications of peptic ulcers are hemorrhage, perforation, and gastric outlet obstruction
- Peptic ulcers include:
 Gastric ulcers that occur on the inside of the stomach
 Duodenal ulcer that occur on the inside of the upper portion of the small intestine (duodenum)
- The most common causes of peptic ulcers are infection with the bacterium Helicobacter pylori (H. pylori) and long-term use of aspirin and NSAIDS
 Stress and spicy foods DO NOT cause peptic ulcers
1. However, they can make your symptoms worse
Stomach Cancer
Stomach Cancer
- Development of malignant tumors in the stomach - Mostly related to sensation of obstructed GI tract
 Can block the passage of food  Full after little food
 Can spread to other organs through  Abdominal pain
 Direct contact  Weight loss
 Blood/lymph flow  Heartburn, ulcer symptoms
Demographics  Nausea, vomiting
- Worldwide, stomach cancer is the 2nd cause of death by cancer  Ascites
- Usually in people over 60 years old  Possible anemia, blood in the stool
- Associated with… Treatment
 Tobacco use - Treated according to stage
 Stomach surgery - Combinations of…
 Obesity  Chemotherapy
 Diet high in salt, smoked, pickled foods  Radiation
Etiology  Surgery
- Most are adenocarcinomas (involving glandular cells) - Chemotherapy may be used before and after surgery
- Triggers are not always clear Medications
 Appears to be related to smoked, pickled, salted foods - Chemotherapeutic agents
 Most patients are H. pylori + - Biologic therapies, e.g. monoclonal antibodies to target cancer cells
 Converts nitrates and nitrites into carcinogens Massage Therapy Implications
 Any situation that impedes the production of stomach acids Risks: Stomach cancer is treated aggressively, so clients are likely to be dealing with both cancer and
- Precancerous changes in stomach lining are undetectable treatment challenges. This requires customized adaptation and education in massage therapy for
- Grow to tumors that can block food passage cancer patients
- Invades muscular layer, serous membranes Benefits: skilled massage therapy offers many benefits for cancer patients, including improved sleep
 Metastasis by direct contact and appetite, reduced depression and anxiety, and effective pain management.
- Cells travel through lymph, circulatory system
- Adenocarcinomas = 90-95% of all diagnoses
- Other cancers that grow in the stomach:
 Non-Hodgkin lymphoma
 Carcinoid tumors
 Stromal tumors
Pathophysiology
- Cancer of the stomach, while having decreased in incidence in the US, continues to be a leading cause of cancer deaths worldwide
- Among the factors thought to predispose to stomach cancer are carcinogenic factors in the diet (e.g., N-nitroso compounds and benzo[a] pyrene found in smoked and preserved food) and chronic
gastritis)
- Because there are few early symptoms with this form of cancer, the disease often is far advanced at the time of diagnosis
Disorders of the Large Intestine

Colorectal Cancer
Colorectal Cancer
Definition Risk Factors Massage Therapy Implications
- Development of tumors anywhere in the large intestine - Obesity, sedentariness Risks: All colorectal cancer treatment options require adaptations
- Related to – not synonymous with – colon polyps - Genetic predisposition in massage therapy choices; consult with the client and health care
Demographics  This accounts for a small percentage of diagnoses teams to make informed decisions.
- 3rd cause of death by cancer in US, numbers are going down - Inflammatory bowel disease Benefits: Skilled massage therapy has many benefits to offer cancer
- Men = women  Crohn disease and ulcerative colitis raise cancer risk patients, including improved sleep and appetite, reduced
- Usually over 50 years old (African Americans have higher risk of - Age depression and anxiety, and effective pain management.
earlier onset)  90% of patients are 50 years + Options: For clients who use colostomy bags, ask how to make
- Highly treatable Signs and Symptoms them most comfortable; they will know. Be aware that oil can
Etiology - Anemia (from slowly bleeding tumors) dissolve the adhesive of the colostomy bags.
- Inner lining of colon is epithelium - Constipation, narrowed stools Research: One study suggests that Thai massage boosts
- Often develops adenomas – small polyps - Blood in the stools lymphocytic activity, reduces pain and stress for colorectal cancer
 These aren’t cancer - Lower abdominal pain patients
 They can become malignant - Bowel movements feel incomplete
 Oncogenes are activated - Unintentional weight loss
 Tumor-suppressor genes are suppressed Treatment
- Growths can… - Depends on stage at diagnosis
 Invade deeper layer of the colon - Combination of…
 Invade nearby tissues  Surgery
 Metastasize through lymph system  Internal/external radiation therapy
 Obstruct movement of feces  Chemotherapy
- Why do polyps become malignant?  Biologic therapies, monoclonal antibodies
 High fat foods linger in colon, byproducts are Medications
carcinogenic - Chemotherapeutic agents
 High fat, low fiber diets have statistical correlation with - Biologic therapies, especially monoclonal antibodies
colorectal cancer
 Not necessarily cause-and-effect
Wiley
 colorectal cancer – among the deadliest of malignancies, second to lung in men and third to lung and breast in women.
 Contributing factors – genetics, alcohol and diets high in animal fats and protein, polyps
 Signs and symptoms – diarrhea, constipation, cramping, abdominal pain, rectal bleeding
 Screening includes FOB testing, digital rectal exam, sigmoidoscopy, colonoscopy, and barium enema.
 Tumors may be removed endoscopically or surgically.
- Polyps in Colon
 Slow growing benign growths that arise from the mucosa of the large intestine
 Rarely cause symptoms, but symptoms include diarrhea, blood in feces, and mucus discharge
 Polyps removed by colonoscopy
 May be cancerous
Pathophysiology
- Colorectal cancer, the second most common fatal cancer, is seen most commonly in person older than 50 years of age
- Most, if not all, cancers of the colon and rectum arise in preexisting adenomatous polyp
- Programs that provide careful follow-up for person with adenomatous polyps and removal of all suspect lesion have substantially reduced the incidence of colorectal cancer
- Colorectal Neoplasma
- Adenomas = adenomatous polyps
 Benign
 Tubular, villous, tubulovillous
- Adenocarcinoma
 Malignant/cancerous
 Early screening important for prognosis
Diverticular Disease
Diverticular Disease
- Condition of small or large intestine in which mucosal and - Bleeding - Prevention:
submucosal layers bulge through the muscularis to form a sac: - Abscess  Dily fiber intake of 25-30 grams
a diverticulum - Peritonitis  Up to 64 ounces of liquid
- Usually at descending or sigmoid colon - Perforation, rupture  Vegetarians seldom have diverticular disease
- Infected diverticulae = diverticulitis - Blockage - Treatment for diverticulae not necessary
Demographics - Fistula - Treatment for diverticulitis:
- Common in areas with diets high in animal fats and processed Signs and Symptoms  Antibiotics
grains - Often silent if no infection is present  Clear liquid diet
- Silent without infection - With infection:  Surgery
Etiology  Sudden onset of… Massage Therapy Implications
- Multifactorial:  Bloating Risks: Diverticular disease can look like simple indigestion; massage
 Inefficient colon motility  Nausea therapy may temporarily ease symptoms, leading to a delayed
 Changes in the strength of the colon wall  Fever diagnosis. Any symptoms that persist for 2 week+ should be
 Lack of dietary fiber  Cramping pursued with a doctor. For a diagnosed client, take care with
- Strong contractions of bowel wall can cause bulging if  Severe pain, lower left quadrant abdominal work, and delay anything intrusive until after any
 There is an inadequate supply of bulky fiber Medications infection has resolved.
 There is a problem with the muscle tissue (i.e., Ehlers- - Antibiotics Benefits: Massage therapy may be helpful for pain and anxiety, but
Danlos syndrome) - Analgesics as necessary it is unlikely to have a direct impact on this condition
- Sacs can fill with fecal matter - Anti-inflammatories as necessary Options: Gentle abdominal stroking or holding touch may be
 Potential for infection, abscess, etc. - Antispasmodics deeply relaxing and helpful in incorporating this part of the body
 Fecal matter can harden: fecalith into a beloved whole.
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 Diverticulitis – inflammation of diverticula
 Diverticula are outpouchings of the wall of the colon.
 Symptoms – pain, constipation or increased frequency of defecation, nausea, vomiting, low-grade fever.
 Treatment – high fiber diet, surgical removal of affected colon in severe cases.
Pathophysiology
- Diverticular disease is the general name for a common condition that causes small bulges (diverticula) or sacs to form in the wall of the large intestine (colon)
- Although these sacs can form anywhere in the colon, they are most common in the sigmoid colon (part of the large intestine closest to the rectum)
- Diverticular disease is a condition in which the mucosa and submucosa of the colon herniate through the muscularis layer, and diverticulitis, in which there is an inflammation and gross microscopic
perforation of the diverticulum
- Diverticulosis: The presence of diverticula without associated complications or problems
 The condition can lead to more serious issues including diverticulitis, perforation (the formation of holes), stricture (a narrowing of the colon that does not easily let stool pass), fistulas, and
bleeding
- Diverticulitis: an inflammatory condition of the colon thought to be caused by perforation of one of the sacs
 Several secondary complications can result from a diverticulitis attack
 When this occurs, it is called complicated diverticulitis
Irritable Bowel Syndrome
Irritable Bowel Syndrome

- AKA - Range from inconvenient to incapacitating
- A condition involving digestive dysfunction - Not life-threatening, although it looks like serious conditions
 No major structural changes, i.e., ulcers, diverticulae, fistulae, etc.  Diverticulitis, colorectal cancer, ulcerative colitis, Crohn disease, etc.
- Biopsychosocial disorder: - Recurrent abdominal pain (3 days or more per month)
 Health processes + mood + stress management - Pain with defecation
Demographics - Change in stool frequency and appearance
- Many (most?) don’t seek medical attention - Gas, bloating, headaches, malaise
- Women > men, 2-3:1 Treatment
- Symptoms begin in childhood, usually not diagnosed till adulthood - Highly individualized
Etiology  Examine dietary, stress factors
- We need strong, organized, coordinated colon contractions to move  Common triggers include
through feces, extract water  Nicotine
 Short transit time: diarrhea, dehydration  Alcohol
 Long transit time: constipation  Sorbitol
- 3 main factors in IBS symptoms:  Dairy products
 Hypersensitivity in intestines  Fiber supplements
 Problems with organized peristalsis  Peppermint
 Psychosocial factors (depression, anxiety, others)  Probiotics
- Could be considered a CNS disorder Medications
 Dysfunctional brain-gut axis-feedback loop sensation and motor - Antispasmodics
response - Fecal binders
 Frequently appears with chronic fatigue syndrome, fibromyalgia - Bulking agents
- A subset of patients may begin with long-term, low-grade gut - Laxatives
inflammation - Antidiarrheals
 Different treatment options for success - Antacids
Types of Irritable Bowel Syndrome - Antidepressants/anti-anxiety medication as necessary
IBS-D - Antibiotics for low-grade infection
- Primary symptoms is diarrhea Massage Therapy Implications
ISB-C Risks: Some clients are so nervous about passing gas that the experience of massage therapy is stressful and unhelpful. If this
- Primary symptom is constipation can be addressed, IBS is safe for massage therapy
IBS-M Benefits: Massage therapy can be an effective way to address stress and the general sense of being able to cope with life’s
- “mixed” – short alternations between diarrhea and constipation challenges. Clients with IBS may find it a powerful tool
IBS-A Options: Address the situation with humor and compassion: “It’s not a good massage until somebody farts.”
- “Alternating” – longer alternations between diarrhea and constipation Research: Massage therapy has been seen to help with IBS and associated disorders, especially fibromyalgia
Wiley
Irritable bowel syndrome (IBS) – disease of the entire gastrointestinal tract in which a person react to stress by developing symptoms (such as cramping and abdominal pain) associated with alternating
patterns of diarrhea and constipation. Excessive amounts of mucus may appear in feces; other symptoms include flatulence, nausea, and loss of appetite. The condition is also known as irritable
colon or spastic colitis
Pathophysiology
- Irritable bowel syndrome (IBS) is a common disorder that affects the large intestine
- Irritable bowel syndrome is characterized by a variable combination of chronic and recurrent intestinal symptoms, that are not related to a structural or biochemical abnormality
- Signs and symptoms include cramping, abdominal pain, bloating, gas, and diarrhea or constipation, or both
- IBS is a chronic condition that needs long-term management
- Only a small number of people with IBS have severe signs and symptom
- Some people can control their symptoms by managing diet, lifestyle and stress
- More severe symptoms can be treated with medication and counseling
- IBS doesn’t cause changes in bowel tissue or increase your risk of colorectal cancer
- Irritable bowel syndrome (IBS) is also known as spastic colon, spastic constipation, irritable colon and nervous indigestion. It is a motility disorder which is strongly associated with anxiety, stress or depression in over half the cases
- Most common gastrointestinal disorder in Western society
- “common cold of the stomach”
- Occurs often in women
- Starts in childhood or early adulthood
- No underlying organic cause or physical abnormality
- Contributing Factors:
 Disruption and incoordination of the natural peristaltic actions and mass movement of the colon
 There may be autonomic dysfunction, notably with response to stress
 Food intolerance
1. Common food intolerances include: wheat, coffee, dairy products, yeast and citrus fruit
- Symptoms
 Emotional stress, fatigue, alcohol and eating, especially consuming meals high in fat, roughage or fruit
 Accompanied by constipation, diarrhea or both
 Steady or intermittent pain in the lower abdomen
1. Can be dull with sharp cramps occurring after eating or in the morning
2. Results from increased pressure of fecal matter in colon or gas build-up
 Incomplete evacuation of the feces
 Others:
1. Bloating, nausea, vomiting, anorexia and halitosis
2. Hemorrhoids
3. Anxiety and depression
 Prognosis isn’t good, considered a chronic and reoccurring disorder
 Can be treatment with diet and relaxation strategies
 Common in:
1. Ulcerative colitis
- Contraindications
 Hydrotherapy applications of heat on the abdomen should not be used if the client has any history of increased blood pressure or cardiovascular problems
1. Also, they would not be used if the client has a flare-up
 Diarrhea is a contraindication to abdominal massage
- Assessments
 Special tests
1. Rebound test will be negative
- Differentiating Other Conditions
1. Inflammatory bowel disease
 Ulcerative colitis results in bloody and loose stools
 Crohn’s disease results in abdominal, hip and low back pain (relieved after passing gas)
 Arthritis in 25%
2. Appendicitis
 Positive rebound test
 Symptoms are nausea, vomiting, low-grade fever and pain in lower right quadrant
 May be mistaken for Crohn’s disease, gall bladder attack, kidney infection, ruptured ectopic pregnancy, ovarian cyst or hemorrhaging ovarian follicle (if in menstrual cycle)
3. Obstruction of the colon
 Medical emergency in the young and elderly
 Absence of defecation, distention of abdomen, vomiting and pain
 98% it’s a block of the rectum resulting in leakage of fecal matter
 A client with constipation who has a sudden unexplained change in patterns for 2 weeks should be referred to a physician and could indicate an obstruction, inflammatory bowel disease or tumor
- Massage
 See constipation for treatment
 May be less pressure if client is sensitive
 Relaxation is a key component
 Abdominal massage is appropriate
- Self-care
 Similar to constipation
Disorders of the Accessory Organs

Cirrhosis
Cirrhosis
Definition Etiology continued… Signs and Symptoms
- From “kirrhos” = “yellow condition”  Nonalcoholic fatty liver disease is now a significant - Signs and symptoms may not be obvious until damage is
 Jaundice is a common indicator contributor advanced (efficient compensation)
- Result of long-term liver damage:  Complication of obesity, type 2 diabetes, high - Early signs:
 Healthy hepatocytes are crowded out, replaced with triglycerides  Nausea, vomiting, weight loss, rashes
scar tissue  Can progress to nonalcoholic steatohepatitis - Later signs:
- Liver function is impaired (inflammation of fatty tissue in the liver)  Complications
 Can be serious or fatal  Anything that might obstruct a duct: Treatment
Demographics  Gallstones - Prognosis in early stages is good if damaged can be stopped
- Traditionally a complication of hepatitis C or alcoholism  Pancreatic cancer - Medications to manage symptoms
 Soon, add nonalcoholic fatty liver disease  Malformed bile duct - Vitamins, minerals
Etiology  Heart failure - With hepatitis, treatment with interferons and other drugs
- Liver is built of highly organized hepatocytes Complications - Steroids if necessary
 Produces bile, clotting factors, many other important - Portal hypertension: liver is congested, cannot accept blood - Surgical repair of varicosities
secretions from portal vein - Liver transplant
- Can regenerate, compensate for damage, but… - Splenomegaly (spleen can’t drain into portal vein) Medications
- Chronic, long-term irritation and/or infection - Ascites, pleural effusion - Diuretics
 Suppresses healthy cell growth - Internal varices - Beta-blockers
 Promotes scar tissue growth - Bleeding, bruising - Antacids
 Nodules develop: “hobnailed liver” - Osteoporosis - Levulose
- Scar tissue blocks the flow of liver secretions - Muscle wasting - Steroidal anti-inflammatories
- Major factors in cirrhosis - Jaundice - Interferon
 Alcoholism - Systemic edema Massage Therapy Implications
 Hepatitis C - Hormone disruption Risks: Complications of cirrhosis can contraindicate rigorous
- Encephalopathy massage therapy. Patients lose the ability to adapt to change
- Liver failure environments, and become frail and fragile
- Liver cancer Benefits: Gentle work that invites calm and reduces anxiety may be
helpful for a person with this disease.
Wiley
Cirrhosis – distorted or scarred liver as a result of chronic inflammation due to hepatitis, chemicals that destroy hepatocytes, parasites that infect the liver, or alcoholism; the hepatocytes are replaced by
fibrous or adipose connective tissue. Symptoms include jaundice, edema in the legs, uncontrolled bleeding, and increased sensitivity to drugs.
- Cirrhosis represents the end stage of chronic liver disease in which much of the liver’s functional tissue has been replaced by fibrous tissue that disrupts venous blood flow predisposing to portal
hypertension and its complications, loss of liver cells, and eventually liver failure
- Alcoholic Liver Disease
- Fatty liver (steatosis)
 Liver cells contain fat deposits; the liver is enlarged
- Alcoholic hepatitis
 Liver inflammation and liver cell failure
- Cirrhosis
 Scar tissue partially blocks sinusoids and bile canaliculi
- Portal Hypertension
 Portal hypertension is an increase in the pressure within the portal vein, which carries blood from the digestive organs to the liver
 The most common cause is cirrhosis of the liver, but thrombosis (clotting) might also be the cause
- Veins Draining into the Hepatic Portal System
 Portal hypertension causes pressure in these veins to increase
 Collateral channels and shunts develop
 Organs engorge with blood
Gallstones
Gallstones
- Concentrated deposits of bile salts or pigment stones in the gallbladder - Obstruction of a duct can lead to…
- Gallbladder = cholecyst  Jaundice; Acute pancreatitis; Cholecystitis, infection; Abscess, rupture, peritonitis;
- Gallstone = cholelithiasis Fibrosis; Gallbladder cancer
- Inflammation of the gallbladder = cholecystitis Signs and Symptoms
- Stones in the bile duct = choledocholithiasis - Gallstones are silent until they are caught in a duct, then…
- Inflamed ducts = cholangitis  Extreme local pain (biliary colic)
Demographics  Can induce nausea, vomiting
- Probably 20% of those over 65 have gallstones in US  Refers between scapulae, right shoulder
Etiology  If the stone gets stuck, must be surgically removed
- Bile is delivered to the gallbladder via the hepatic duct and cystic duct Treatment
- After a fatty meal, hormonal commands cause the gallbladder to release bile into the cystic duct, - Laparoscopic cholecystectomy
then the common bile ducts, then duodenum - Scope to diagnoses, remove or dislodge stones while sparing the gallbladder
- Pancreatic secretions also use the common bile duct to access the duodenum - Medication to dissolve stones, prevent new ones
- Bile emulsifies fats for digestion; without bile the fats clump together and are harder to break - After surgery:
down  Bile is still produced, dripped into duodenum instead of concentrated for high-fat meals
- When cholesterol or bilirubin are in high concentration, they can become granules  May require some vitamin supplements
 Bile sludge Medications
 Larger stones - Analgesics
- Most gallstones are made of cholesterol - Medications to dissolve small cholesterol-based stones
- Risk factors: Massage Therapy Implications
 Obesity; Estrogen; Race; Gender (women > men); Cholesterol-lowering drugs; Diabetes; Risks: Acute biliary colic contraindicates massage, mainly because of pain. If stones have been
Rapid weight loss, bariatric surgery; Fasting; History of previous gallstones; Other diseases identified and not removed, take care at the right costal angle
Benefits: Someone with a history of stones and no current symptoms can enjoy all the benefits or
massage therapy as the rest of the population.
Wiley
- Gallstones
 If bile contains insufficient bile salts, lecithin or excessive cholesterol, cholesterol may crystallize to form gallstones
 Gallstones may cause obstruction to the flow of bile from the gallbladder into the duodenum
 Treatment includes gallstone-dissolving drugs, lithotripsy (shock-wave therapy) or surgery
 If unsuccessful cholecystectomy (removal of gallbladder and its contents)
 If done lifestyle and dietary changes are done
 Limiting the intake of saturate fats
 Avoiding the consumption of alcoholic beverages
 Eating smaller portions of food but eating more frequently
 Taking vitamins and mineral supplements
Pathophysiology
- AKA Cholestasis
- Bile flow in the liver slows down
- Bile accumulates and forms plugs in the ducts
 Ducts rupture and damage liver cells
1. Alkaline phosphatase released into blood
- The liver is unable to continue processing bilirubin
 Increased bile acids in blood and skin
1. Pruritus (itching)
- Bile in the Intestines
- Emulsifies fats so they can be digested
- Passes on to the large intestine
 Bacteria convert it to urobilinogen
1. Some is lost in feces
2. Most is reabsorbed into the blood
 Returned to the liver to be reused
 Filtered out by the kidneys  urine
Hepatitis
Hepatitis
Definition Types of Hepatitis Signs and Symptoms
- Inflamed liver Hepatitis A (HAV) - Varies by person and type of virus, but in general:
- Viral hepatitis - Spreads most efficiently through oral-fecal contamination  Malaise
 Hepatitis A, B, C cause about 90% of all infections in US  Intimate fluids can also work, but less efficiently  Weakness
 Viruses A-G have been identified - Short, acute infection, no long-lasting damage  Fever
- Liver inflammation without viral infection is usually - Incubates 2-6 weeks, present 2-3 weeks, several months of  Nausea
nonalcoholic steatohepatitis (NASH) convalescence  Food aversion;
Demographics - One exposure = lifelong immunity  Jaundice
- Up to 30% of all adults have been exposed to hepatitis A Hepatitis B (HBV) - HAV presents clearest, most severe symptoms
- Many don’t know they have hepatitis B - Spreads through intimate fluids - HBV, HCV present subtler, long-term symptoms (but cause
- Hepatitis C  Stable outside a host, can be spread through more damage)
 High risk of long-term liver disease contaminated surface, i.e., needles, toothbrushes that Treatment
 Most common blood-borne infection in US touch - HAV: immunoglobulin injection (equine antibodies)
- NASHA affects 2-5% in US - Long-term infections, subtle symptoms related to inflammation - HBV, HCV: antiviral agents, rest, supportive therapies
Etiology of liver  Antiviral medications can cause serious side effects
- Hepatitis A, B, C – viral infections of the liver - Incubates 2-6 months, resolves within 15 months - If enough function is lost, liver transplant
- They are unrelated; exposure to one confers no protection  Infants, children, and about 5% of adults become long- Medications
from others term carriers - HAV: immunoglobulin injection
- Viral attack on liver stimulates inflammatory response  At risk for liver cancer, cirrhosis, etc. - HBV, HCV: combinations of antiviral agents
 Blood tests show liver enzymes, antibodies Hepatitis C (HCV) Massage Therapy Implications
Etiology: 4 Phases - Probably spread most efficiently through intimate fluids Risks: Hepatitis has several possible complications that may
- Phase 1 - 75% develop chronic disease contraindicate massage therapy. Anything that exerts adaptive
 New infection, viral replication, liver compensation  Of them, 1-5% are likely to die from complications stress may present too much challenge for a client who is
 Blood tests are positive related to HCV struggling with a hepatitis infection
- Phase 2 - Damage accrues very slowly, over decades Benefits: Massage therapy that is within the bounds of a person’s
 Prodrome: symptoms develop  Communicable during this time ability to adapt may be supportive and helpful, especially in dealing
 Food aversion, nausea, vomiting, malaise Other Forms of Hepatitis with some of the medication side effects. A person who has full
- Phase 3 - Hepatitis D: only seen alongside HBV recovered with no long-term impacts on health is a good candidate
 Icteric stage: jaundice, pale stools, dark urine, - Hepatitis E-G: uncommon for massage therapy.
hepatomegaly - Other viruses may cause liver inflammation:
- Phase 4  Epstein-Barr, cytomegalovirus
 Convalescence: liver heals, symptoms resolve, health is - Nonviral hepatitis
restored  From alcohol, drug use, fatty liver disease
 From autoimmune disease
Wiley
 Hepatitis – inflammation of the liver that can be caused by viruses, drugs, and chemicals, including alcohol.
 Several types of viral are recognized:
 Hep A – infectious hepatitis. Caused by the Hep A virus and is spread through fecal contamination of objects such as food, clothing, toys, and utensils.
 Generally is a mild disease of children and young adults characterized by loss of appetite, malaise, nausea, diarrhea, fever, and chills. Eventually jaundice appears.
 Does not cause lasting liver damage. Most people recover in 4-6 weeks.
 Hep B – caused by the Hep B virus
 Spread primarily by sexual contact and contaminated syringes and transfusion equipment
 Can also be spread by saliva and tears
 Can be present for years or a lifetime and can produce cirrhosis or liver cancer.
 Vaccines produced through recombinant DNA are available to prevent Hep B infection.
 Hep C – caused by the Hep C virus
 Clinically similar to Hep B.
 Can cause cirrhosis and possibly liver cancer
 Hep D – caused by Hep D virus
 Transmitted like Hep B and a person MUST have been co-infected by Hep B before contracting Hep D
 Results in severe liver damage and has a higher fatality rate than infection with Hep B alone.
 Hep E – caused by the Hep E virus.
 Does not cause chronic liver disease but has a very high mortality rate among pregnant women
Pathophysiology
- The word “hepatitis” means “inflammation” of the liver
- Hepatitis can be caused by many things such as physical injury, bacterial infections, adverse drug interactions, and viruses
- There are currently 5 viruses identified that specifically attack the liver and cause “viral hepatitis” or inflammation of the liver due to a virus
- All of the hepatitis viruses cause a new or “Acute” infection
- But only the hepatitis B and C viruses can result in a “chronic” infection that increases the risk of a person developing cirrhosis, liver failure of liver cancer
- Viral hepatitis is caused by hepatitis viruses, A, B, C, D, and E, which differ in terms of mode of transmission, incubation period, mechanism, degree and chronicity of liver damage, and ability to evolve
to a carrier state
- Autoimmune hepatitis involves the immune destruction of hepatocytes causing inflammation
- Hepatitis A
 Hepatitis A (infectious hepatitis) is caused by the hepatitis A virus and is spread via fecal contamination of objects such as food, clothing, toys, and eating utensils (fecal-oral route)
 It is generally a mild disease of children and young adults characterized by loss of appetite, malaise, nausea, diarrhea, fever, and chills
 Eventually, jaundice appears
 This type of hepatitis does not cause lasting liver damage
 Most people recover in 4-6 weeks
- Hepatitis B
 Hepatitis B is caused by the hepatitis B virus and is spread primarily by sexual contact and contaminated syringes and transfusion equipment
 It can also be spread via saliva and tears
 Hepatitis B virus can be present for years or even a lifetime, and it can produce cirrhosis and possibly cancer of the liver
 Individuals who harbor the active hepatitis B virus also become carriers
 Vaccines produced through recombinant DNA technology (for ex., Recombivax HB) are available to prevent hepatitis infection
- Hepatitis C and D
 Hepatitis C, caused by the hepatitis C virus, is clinically similar to hepatitis B
 Hepatitis C can cause cirrhosis and possibly liver cancer
 In developed nations, donated blood is screened for the presence of hepatitis B and C
 Hepatitis D is caused by the hepatitis D virus
 It is transmitted like hepatitis B, and in fact a person must have been coinfected with hepatitis B before contracting hepatitis D
 Hepatitis D results in severe liver damage and has a higher fatality rate than infection with hepatitis B virus alone
- Hepatitis E
 Hepatitis E is caused by the hepatitis E virus and is spread like hepatitis A
 Although it does not cause chronic liver disease, hepatitis E virus has a very high mortality rate among pregnant women
- Chronic Viral Hepatitis
 The principal cause of chronic liver disease, cirrhosis and hepatocellular cancer in the world
 Chief reason for liver transplantation in adults
 Caused by HBV, HCV, and HDV
Liver Cancer
Liver Cancer
- AKA: hepatocellular carcinoma - Easy to miss early signs (hidden by cirrhosis)
- Cancer that originates in the liver  Vague abdominal pain, becomes increasingly intense
 As opposed to metastasizing from elsewhere (metastatic liver  Unintended weight loss, food aversion
disease)  Muscle wasting
Demographics  Ascites
- Fastest-growing cause of cancer  Fever
 Diagnosis has doubled in 20 years  Abdominal mass
 Related to fatty liver disease, HBV, HCV  Jaundice
- Usually diagnosed in people over 65  Blood tests show abnormal hormones, enzymes
- Men > women Treatment
Etiology - Difficult to treat successfully
- Uncontrolled, disorganized replication of hepatocytes  5-year survival is rare
- Often triggered by long-term inflammation or infection  Recurrence is common
- Tumors may develop singly or throughout the liver  Often doesn’t respond to typical treatment options
- Risk factors:  Comorbidity with cirrhosis make treatment more difficult
 HBV infection, especially if contracted in infancy, childhood Medications
 HCV infection - Chemotherapeutic agents
 Alcohol abuse, especially in combination with hepatitis - Oral anti-angiogenic agents
 Hemochromatosis: blood disorder with too much iron - Injections of ethanol
 Nonalcoholic fatty liver disease: can lead to cirrhosis and - Medications to manage complications
cancer Massage Therapy Implications
 Cirrhosis: almost always precedes cancer Risks: Aggressive therapies with surgery and surgical devices demand caution
 Aflatoxin B1: from a mold that grows on peanuts, common in Benefits: Liver cancer and treatment is extremely challenging. Any massage therapy that can promote relaxation and manage
Asia, sub-Saharan Africa stress could be helpful, if it can be given without creating more risks
Pancreatic Cancer
Pancreatic Cancer
Definition Types of Pancreatic Cancer Treatment
- Cancer that begins in the pancreas Adenocarcinoma of the Pancreas - Most cases are advanced when diagnosed
- Usually in exocrine ducts, can affect hormone-producing cells - At the endocrine ducts - Resection of pancreas can be successful if early enough
Demographics  Affects secretion of digestive enzymes  May remove the gallbladder, part of stomach, small
- 4th cause of death by cancer in US  May block the pancreatic duct intestine too
Etiology  Most common form, about 96% of all cases  Recurrence is still high
- Mutations of cells lead to the growth of life-threatening tumors Neuroendocrine Tumors of the Pancreas - If inoperable…
 Adenocarcinomas at exocrine ducts - At the islet of Langerhans cells  Chemotherapy
 Neuroendocrine tumors at islets of Langerhans cells  Impacts the ability to regulate blood glucose  Targeted therapy
- Tumors grow quickly, invade nearby tissues through direct Signs and Symptoms  Radiation to slow growth
contact - Early Medications
- Can also metastasize through blood, lymph  Abdominal discomfort - Chemotherapy
- Risk factors:  Mid-back pain - Biologic, targeted therapy
 Age  Loss of appetite, weight loss - Narcotic agents, antidepressants, anti-emetics
 Race - Later Massage Therapy Implications
 History of smoking  Jaundice (if the common bile duct is obstructed) Risks: Any massage therapy in this context is likely to be in a
 History of type 2 diabetes  Pruritis hospice setting, and must be carefully gauged to the client’s
 Chronic pancreatitis  Indigestion fragility.
 Obesity  Ascites Benefits: Skillful massage therapy may help to ease pain, anxiety,
 Inherited characteristics  Enlarged liver, spleen constipation, and other discomforts for a person with this
 Difficulties with blood sugar (neuroendocrine tumors) extremely challenging, and often terminal disease.
Wiley
 Pancreatic cancer
 Occur in 50+ years of age; male more likely
 Few symptoms before metastasizing to lymph nodes, liver, or lungs
 Nearly fatal and 4th common cause of death in the US
 Linked to fatty foods, high alcohol consumption, genetic factors, smoking and chronic pancreatitis
Pathophysiology
- Pancreatic cancer is now the fourth leading cause of death from cancer in the US, preceded only by lung, colon and breast cancer
- Pancreatic cancer, the cause of which is unknown, is considered to be one of the deadliest malignancies
- The most common pain is a dull epigastric pain often accompanied by back pain, often worse in the supine position, and relieved by sitting forward
- Most cancers of the pancreas have metastasized at the time of diagnosis
- Surgical resection of the tumor is done when the tumor is localized or as a palliative measure
- Radiation therapy may be useful when the disease is localized but not resectable
- The use of irradiation and chemotherapy for pancreatic cancer continues to be investigated
- Pain control is one of the most important aspects in the management of person with end-stage pancreatic cancer
Pancreatitis
Pancreatitis
Definition Types of Pancreatitis Treatment
- Inflammation of the pancreas Acute Pancreatitis - Depends on cause
- Can be acute of chronic - Sudden onset related to blockage - No food by mouth for a few days
Demographics  Gallstones - Surgery if necessary
- Acute pancreatitis:  Blunt trauma - Oral digestive enzymes
 Men > women  Congenital malformation Medications
 African Americans more than other groups  Cystic fibrosis - Antibiotics if necessary
Etiology  Other problems - Analgesics
- Pancreatic exocrine secretions are made in acinar cells - Usually short, with full recovery - Supplementary digestive enzymes
 Bicarbonate - Can be dangerous, severe, life-threatening Massage Therapy Implications
- If the ducts are blocked, or if abscesses or cysts are present, Chronic Pancreatitis Risks: A client with undiagnosed abdominal and mid-back pain may
the pancreas is damaged - Long term wear and tear leads to irreversible damage ask for massage therapy. If symptoms do not respond, this is
 Autodigestion  Scarring and fibrosis reason to refer out.
Signs and Symptoms  Pancreatic stones Benefits: Clients who are treating their pancreatitis or who have
- Dull upper abdominal pain - Usually related to alcohol abuse recovered can benefit from any types of massage therapy that is
 Sudden or gradual onset - Can also be related to… within their capacity for adaptations
- Nausea, vomiting, diarrhea, fever, rapid pulse  Cystic fibrosis
- Mid-back pain  Congenital anomaly
- Weight loss, malabsorption of nutrients, jaundice, problems  Autoimmune disease
with blood glucose regulation  Gallstones
- With chronic pancreatitis
 Episodic pain; increasing frequency
Wiley
 Pancreatitis is the inflammation of the pancreas
 may occur due to alcohol abuse or chronic gallstones
 more sever acute pancreatitis
 due to heavy alcohol intake or biliary tract obstruction, pancreatic cells may release either trypsin instead of trypsinogen or insufficient amounts of trypsin inhibitor and begins digesting
the pancreatic cells
 may be idiopathic (unknown) others include cystic fibrosis, high levels of calcium in the blood (hypercalcemia), high levels of blood fats (hyperlipidemia or hypertriglyceridemia), some
drugs, and certain autoimmune conditions BUT 70% is due to alcoholism
 happens between 30-40
Pathophysiology
- Acute pancreatitis is an inflammatory condition of the pancreas due to inappropriate activation of pancreatic enzymes, with manifestations that can range from mild to severe and life-threatening
- Chronic pancreatitis causes progressive destruction of the endocrine and endocrine pancreas
 It is characterized by episodes of pain and epigastric distress that are similar to but less severe than those that occur with acute pancreatitis
- Chronic Pancreatitis and Pancreatic Cancer
- Have signs and symptoms similar to acute pancreatitis
- Often have:
 Digestive problems because of inability to deliver enzymes to the duodenum
 Glucose control problems because of damage to the islets of Langerhans
 Signs of biliary obstruction because of underlying bile tract disorders or duct compression by tumors
Other Digestive System Conditions

Candidiasis
Inflammatory Bowel Disease

Constipation
- Constipation is the slow, difficult or infrequent movement of feces through the bowel
- Considered a symptom rather than a condition
- 25% of the pop.
- Average elimination is once a week or 3 times a week
 Differences based on diet (high fiber)
 3 times a day
- Movement in the Digestive System
 Enteric and autonomic nervous system (both para and sympathetic)
 Para supports digestion
 Sympathetic inhibits
 Movement in the colon:
 Segment movements
 Mixing movement so absorption can occur through intestinal walls
 SI nutrients and LI water and electrolytes
 Propulsive contractions
 Move the fecal matter through the colon toward anus
 Peristalsis
 Smaller and frequent propulsive contractions
 Mass movements
 Refers to infrequent powerful propulsive contractions in the LI
 24-hr period 4-6 (200 mmHg)
 Influences by intraluminal pressure (pressure created by the volume fecal matter)
- Transit Times
 Transit time refers to the speed which fecal matter moves through the large intestine
 Optima time results in soft stool
 Average time 24-48 hrs
 Decrease may be a result of increase in segmenting movements and a decrease in propulsive movement
 The opposite in diarrhea sometimes called hyperperistalsis
 Mass movements are 50% less frequent and for a shorter duration in those with constipation
 This results in more time for water to absorb
 Hormones, emotions and diet also effect transit time
 Fear and anxiety increase motility, especially segmentation
 Depression results in reduced bowel activity
 Enterogastrone slows down stomach contraction
 Gastrin or secretin increase mass movements in the LI
 High fibre and adequate water intake results in bulkier but soft stools
 Low fibre, high fat, highly processed foods and diuretic foods result in longer transit times and hard stools
 High saturate fat diet leads to an increase in colorectal cancer
- Autointoxication
 Those with constipation also suffer from other symptoms like headaches, nausea and irritability
- Elimination
 Internal anal sphincter (part of the parasympathetic nervous system) opens when pressure occurs on the walls of the distal colon
 External anal sphincter (part of the somatic nervous system) opens voluntarily and may be ignored
 The diaphragm and abdominal muscles also increase intrapelvic pressure while low back and gluteal muscles relax
- Causes of constipation
 Lifestyle factors include:
 Poor diet
 Low fiber and water intake or low food intake
 Sedentary lifestyle
 Resisting the urge
 Stress
 Postural imbalances
 Physiological factors include:
 Poor muscle control or muscle tone or lack of coordination
 Muscular weakness
 Psychological factors
 Depression, eating disorders, obsession with “cleanliness”, denial of the actions or addiction or laxatives or purgative (ex. enemas)
 Medication side effects
 Opiates, anticholinergics (block parasympathetic nerve), antidepressants and anticonvulsives
 Post-surgery effects
 Abdominal surgery resulting in paralytic ileus
 Absence of motor activity in the LI for 72 hours, and the stomach and SI for 24 hours
 Gastrointestinal conditions
 Irritable bowel syndrome, diverticular disease, megacolon, obstruction, colorectal cancer and Hirschsprung’s disease
 Physiological and structural disorders
 Rectal prolapse or internal and external sphincter abnormalities
 Pregnancy and early postpartum
 First 6 weeks after childbirth
 Other disorders
 Hypothyrdoism, hypercalcemia and diabetes
 Parkinsons, multiple sclerosis and sacral lesions
- Laxatives
 Bulk laxatives increase the ability of fecal matter to hold water
 Laxative containing salts such as magnesium hydroxide or salphates retain water
 Laxatives containing unabsorbed sugars and polyhyrialcohol use bacteria found in the intestine to retain water
 Laxative such as senna, cascara and aloe (aka arthraquinone laxatives)are from plants stimulate colon motility
 Use of laxative can lead to colon atrophy of the mucous layer resulting in a “cathartic colon” causing constipation, electrolyte imbalance and seepage of fecal fluid from the anus
 Diet wise fibre provides the same benefits, 35 grams per day, can reduce transit time by half, increase fecal bulking and increase colon motility
 Should be introduced gradually to reduce bloating, flatulence and diarrhea
- Symptoms
 Straining, pain or discomfort may be experienced when passing stools
 Infrequent bowel movements occur.
 These will be different for each person; from every day to 3 times a week is considered normal
 Hard stool, which may be small “rabbit” or “pellet” stools, are passed
 These may be interspersed with soft stool or diarrhea AKA irritable bowel syndrome (IBS)
 Abdominal pain, cramps or discomfort may occur intermittently
 Low back pain or discomfort can result
 May refer to the sacrum
 Bloating and flatulence are experienced
 Hemorrhoids can result from straining due to large or hard stools
 A bad taste in the mouth, bad breath (halitosis), nausea and a lack of appetite can result due to the slowing of gastric emptying which results with constipation
 Headaches, irritability and malaise seems to result reflexively from the distention of the rectal wall
- Objective Information
 Observation / Posture
 Bloating of the abdomen
 Hyperlordosis leads to short psoas muscle which is in contact with the colon
 Stretched and weak abdominal muscles can lead to bearing down for defecation
 Posterior pelvic tilt results in shortened diaphragm and abdominal muscles resulting in compression of abdominal contents
 Palpation
 Abdomen may feel firm or present with tenderness
 Hypertonicity (diaphragm and glutes) or hypotonicity of the abdominal muscles
 Range of Motion
 muscles will show decreased range and weakness
 Special Tests
 Rebound Test will be negative for general constipation
- Differentiating Other Conditions
 Inflammatory bowel disease
 Ulcerative colitis results in bloody and loose stools
 Crohn’s disease results in abdominal, hip and low back pain (relieved after passing gas)
 Arthritis in 25%
 Appendicitis
 Positive rebound test
 Symptoms are nausea, vomiting, low-grade fever and pain in lower right quadrant
 May be mistaken for Crohn’s disease, gall bladder attack, kidney infection, ruptured ectopic pregnancy, ovarian cyst or hemorrhaging ovarian follicle (if in menstrual cycle)
 Obstruction of the colon
 Medical emergency in the young and elderly
 Absence of defecation, distention of abdomen, vomiting and pain
 98% it’s a block of the rectum resulting in leakage of fecal matter
 A client with constipation who has a sudden unexplained change in patterns for 2 weeks should be referred to a physician and could indicate an obstruction, inflammatory bowel disease or tumor
- Contraindications
 Hydrotherapy applications of head on the abdomen should not be used if the client has any history of increased blood pressure or cardiovascular problems
 Heat would not be used if the client has an inflammatory bowel disease that is flaring up
 Diarrhea is a contraindication for abdominal massage
- Treatment Plan
 Treatment Goals:
 Hydrotherapy
 Warm may be used to increase local circulation
 Cool or cold applications act to stimulate the colon
 Either will cause a reflexive decrease in sympathetic nervous system firing
 Positioning
 Pillow under the abdomen in prone
 90° of hip flexion for abdominal massage supine or feet flat on table
 Reduce stress
 Decrease pain  decrease sympathetic nervous system firing
 Address postural imbalance
 Decrease trigger points in the lumbar spine, iliopsoas and gluteals
 Diaphragmatic breathing  decrease congestion in the abdomen
 Increase circulation in the abdomen
 Move fecal matter
 Pressure is done in a clockwise direction
 Maintain range of motion
 Rocking or PROM
- Self-care Plan
 Hydrotherapy (same as above)
 Epsom salt baths
 Self-massage
 General exercise
 Walking or swimming, Tai Chi or yoga
 Movement after eating is beneficial
 Refer client
 Naturopathy or nutritionist
 Stretch and strengthening
 May introduce lavender
 Educate client
 2 times a week for 2 weeks then once a week for 2 week
 If postural imbalance may be different
 If chronic pathology or medication may be ongoing treatment
Endocrine System Conditions

Diabetes Mellitus
Diabetes Mellitus
Definition  Ulcers, gangrene, amputations Signs and Symptoms
- Diabetes = “siphon” or “pass-through”  From systemic atherosclerosis - Can be subtle and non-specific:
- Mellitus = “sweetened with honey”  Nerve damage  Polyuria (increase urine); polydipsia (increased thirst);
- Diabetes mellitus = “sweet pee”  73,000 amputations/year polyphagia (increased eating)
- A group of disorders all resulting hyperglycemia  Kidney disease  Fatigue
- Type 1 and 2 = 98% of all diagnoses  #1 cause of end stage renal failure, need for  Weight loss
Demographics transplant  Nausea
- Some estimates say 29 million in US have type 2  Impaired vision from…  vomiting
 About 8 million don’t know it yet  Thickened capillaries in eyes - Signs of complications
 1.6 million DM2 diagnoses/year  Glucose in the lens - Most people have probably had DM2 for 4-7 years at the time
- 1 million in US have type 1  #1 cause of new blindness in 20-74 years old of diagnosis (risk of secondary organ damage is high)
 16,000 DM1 diagnoses/year  Neuropathy Diabetic Emergencies
- Costs $245 billion/year in direct and indirect health care  Can be of motor, sensory, autonomic nerves - Ketoacidosis:
expenses  Tingling, pain, numbness  Shortage of insulin, lack of glucose in cells for DM1
Etiology  At the vagus nerve, can lead to  Body partially metabolizes fats, by-products are acidic
- Muscles, brain cells, and others do best with glucose for fuel  Problems with postural blood pressure - Hyperosmolality:
 Glucose must be escorted through the cell membranes  Poor digestive motility  Similar to ketoacidosis for DM2
by insulin  Impotence  Paid, extreme change in pH can lead to shock, coma,
- Insulin is made in beta cells of the pancreas  Hypoglycemia insensitivity death
 Takes sugar from the blood into hungry cells  Others - Insulin shock:
 Takes fat from the blood into lipid storage cells  Can affect all systems  Too much insulin circulated, BG is dangerously low
- Diabetes develops when…  Urinary tract infection, dental cavities, ear  Dizziness, confusion, weakness, tremors
 Insulin is in short supply infections, birth defects…  Can lead to coma and death
 Insulin receptor sites are resistant Types of Diabetes Mellitus Treatment
 BOTH Type 1 diabetes mellitus (DM1) -Treatment goals:
- DM1 is autoimmune: the immune system attacks and destroys - Used to be known as insulin-dependent diabetes mellitus  Improve insulin production is possible
beta cells - Autoimmune attack on beta cells; body produces no insulin  Inhibit sugar release from liver
- DM2 is multifactorial - Goes with increased risk for…  Increase insulin sensitivity in cell membranes
 Genetic predisposition  Hashimoto thyroiditis  Decrease absorption of carbohydrates in small
 Diet and lifestyle  Graves disease intestine
- Risk factors for DM2  Addison disease  Maintain healthy eyes, skin on feet
 Being over 45 years old (although it is often diagnosed - Usually diagnosed before age 30 -DM1: various forms of insulin
in younger people)  Latent autoimmune diabetes in adults (LADA) shows  Via injection or pump
 Being 20% or more over healthy weight later -DM2: changes in diet, exercise
 Family history of diabetes - About 5-10% of all diagnoses  Drugs to manage insulin use
 Racial predisposition Type 2 diabetes mellitus (DM2)  Insulin via injection or pump
 Native American; Hispanic; Pacific Islander; Asian - Used to be called non-insulin dependent diabetes mellitus  Kidney support if necessary
American; African American  Many patients do end up using insulin Medications
 Problems with glucose tolerance - Multifactorial: genetics + habits -Fast- and slow-acting insulin
 Hypertension - Controllable with diet, exercise, drug management -Metformin (sage)
 Gestational diabetes Prediabetes -Medication for hyperlipidemia
 Polycystic ovarian syndrome - Blood glucose levels are higher than normal but not up to -Antihypertensives
- Eating habit findings: diagnostic criteria for DM2 -Medications to manage other complications as necessary
 Fewer animal products correlates to lower DM2 risk - Up to 79 million (35% of all adults) may be in this state Massage Therapy Implications
 More animal products correlates to high DM2 risk  Many will progress to DM2 Risks: A person with poorly managed diabetes and complications is
- Connection isn’t clear Double diabetes likely to have a multitude of health challenges. Massage therapy
 Could be about saturated fats and changes in cell - Starts with DM1, but also develops insulin resistance, and DM2 must not add to challenges, so be sure to watch for skin health,
membranes to make them insulin resistant Other Types of diabetes injection or pump sites, and numbness
Complications - Gestational diabetes: transient case during pregnancy Benefits: Massage therapy has many benefits to offer clients whose
- Many and serious  Can cause birth defects, dangerously big babies disease is well-managed. For those with complications and
 Cardiovascular disease  Increased risk of DM2 for mother and child limitations, massage therapy must likewise be limited to stay
 Atherosclerosis throughout the system - Secondary diabetes: within adaptive capacity.
 Stroke  Result of damage to pancreas Options: Try to schedule sessions for when insulin is at its peak
 Hypertension  Symptoms of other endocrine disorder activity—not too near the beginning or end of a dose cycles. Check
 Aneurysm - Diabetes insipidus on how your client wants to manage hypoglycemic symptoms
 Edema from…  Pituitary dysfunction Research: Research suggests that massage therapy may help to
 Sluggish circulatory return  Insufficient antidiuretic hormone leads to constant drop BG level, but the duration of the effect is not known. Other
 Kidney disease urination + thirst (also pee) research finds that massage therapy may help with some diabetes
biomarkers, and it may positively influence peripheral artery
disease.
Diabetes is a group of metabolic disorders characterized by Early symptoms of diabetes include frequent urination, thirst and Risks: If the circulatory and urinary systems are impaired, a client
problems with glucose metabolism. increased appetite along with weight loss, nausea, and vomiting. with diabetes may have limited capacity to adapt to the changes
These symptoms can be subtle enough that the first indicators of that rigorous massage demands. Advanced disease can result in
disease are the complications it can cause: neuropathy, impaired skin damage and ulcers, especially to the legs and feet; these are
vision, kidney dysfunction, or other problems cautions for bodywork as well. Numbness associated with diabetic
neuropathy can interfere with a client’s ability to give accurate
feedback about pain and pressure. And massage has been seen to
drop blood sugar; clients may experience hypoglycemia if they
have a massage and supplement insulin without adequate food.
Benefits: a client with well-managed diabetes and no
contraindicating complications can enjoy the same benefits from
massage as the result of the population, with the caveat that
massage may temporarily cause a drop in blood sugar, so the client
and therapist should anticipate that possibility.
- Diabetes mellitus is a chronic condition that results in problems with carbohydrate, protein and fat metabolism
- Body’s inability make or use insulin
- Insulin is produced in the pancreas and utilize glucose as the body’s main fuel source
- Results in high glucose in blood (hyperglycemia)
- Leads to starvation and increased breakdown of fat and muscle cells—brain due it being glucose-dependent
- Complications include:
 Vascular problems causing atherosclerosis and hypertension
 Poor tissue health
 Gangrene
 Impotence
 Pregnancy complications
 Kidney disease
 Eye disease  blindness
 Peripheral neuropathies  hands and feet
- Insulin and blood glucose peaks 30 minutes after eating and return to normal after 3 hours
- Controlled with diet and exercise or by insulin injection current
- Types of Diabetes Mellitus
 Type 1 Diabetes Mellitus (DM1)
 Juvenile  affects children and young adults (before 25)
 10% of pop.
 Autoimmune
 Family history
 Prevalent in Black, Aboriginal and Latin American
 Symptoms
 3 P’s: polyuria (increase in urination), polydipsia (excessive third), and polyphagia (extreme hunger)
 High glucose and ketones in urine (glycosuria and ketouria)
 Unusual weight loss
 Extreme fatigue
 Irritability
 Sweet-smelling breath
 Nausea or vomiting
 Hyperglycemia and hypoglycemia
 Could lead to ketoacidosis
 Type 2 Diabetes Mellitus (DM2)
 Inadequate insulin production or utilization
 Linked to poor diet
 Adults (45+)
 Overweight
 Family history
 Inactive
 Prevalent in Black, Aboriginal and Latin Americans
 Symptoms
 Gradual onset, asymptomatic until detected
 Same as DM1
 Frequent infections
 Skin, gum or bladder
 Slow-healing cuts and bruises
 Tingling or numbness in hands or feet (paresthesia)
 Blurred visions
 Fairly stable and easy to control
 Other types
 Impaired glucose tolerance
 Latent form
 May lead to DM
 Levels and utilization is between diabetics and health person
 Gestational diabetes mellitus (GMD)
 Temporary diabetes with onset during pregnancy
 20% of women
 Increased risk of pregnancy complications
 High chance of DM2 in 10 years
- Complications of Diabetes Mellitus
 Ketoacidosis
 DM1 and gestation diabetes
 Gradual onset and prolonged recovery
 Occurs when sodium, potassium and ketones are lost in the urine
 Starts with hyperglycemia (build up on glucose in blood)
 Occurs after emotional or physical stress (pregnancy, infection, illness, surgery, trauma or extreme anxiety [times when body needs glucose])
 Dehydration and electrolyte imbalance
 Fats are broken down and ketones are produced thus lead to high levels in the blood
 Symptoms:
 Warm, dry skin, tachycardia, hypotension, sweet-smell of breath, depression of CNS, lethargy, vomiting, abdominal pain, stupor and coma
 Hyperosmolar nonketotic coma
 1 day to 2 weeks to develop
 Could result in death
 Resistance to insulin leading to excessive carbohydrate intake (high concentration [hyperosmotic] of glucose)
 Draws ISF to kidney leading to increased urination
 Person becomes thirty and dehydrated
 Dry skin and lethargy  coma and seizures
 May be mistaken for a stroke
 Hypoglycemia
 Early sign of DM or error in insulin dose or change in injection site, failure to eat, increased exercise, or stressful situation
 Case CNS problems headache, numbness of the lips and tongue, blurred vision, slurred speech, confusion, euphoria, impaired problem solving and motor function
 Autonomic symptoms include hypotension, feeling hungry ( emotional changes), nervousness and irritability, tachycardia, shaking, sweating and constriction of the peripheral vasculature causing cool, clammy skin
 May result in seizures and coma
 Treats with candy (eating)
 Those without diabetes
 May be a result of the adrenal, thyroid, pituitary, kidney and pancreatic disorders
 Poor diet, increased alcohol and caffeine
 Increase stress levels
 Difference: pain in body (especially eyes), insomnia and increased aggressiveness
 Lasts a few hours after eating sweets or fats
 Severity increases the longer the time between meals
 Small meals are best and cut back on carbs
- Long-Term Complications
 Increase hyperglycemia
 Between 10-15 yrs following onset
 Can become a primary concern
 Infection
 Poor healing time, nerve damage, infection and tissue breakdown leading to ulcers and gangrene
 Lower extremities, mouth, gums, UTI and incisions after surgery
 Derma replacements for ulcers
 Peripheral Neuropathy
 40-50% of those with diabetes
 Lower extremity amputation is 11 X’s more likely
 Microcirculation due to inability for nerves to travels due to lack of nutrition leading to necrosis of the fibers
 Could be compressed due to ischemia
 Distal symmetrical neuropathy
 Most common
 Impaired circulation and sensory losses in the feet resulting in ulcers
 Ankle joint may collapse
 Most distal muscles: dorsiflexors or intrinsic hand muscles then progresses proximally (rare to the knee or elbow)
 Diabetic radiculopathy and polyradiculopathy
 More common in long-term diabetics
 Usually thoracic and lumbar roots are affected
 May be confused with nerve root compression
 Acute burning and hypersensitivity to skin occurs unilaterally
 Minimal sensory loss or weakness
 Max pain levels within a week of onset and persists for several months then gradually resolves
 Could be reoccurring experience
 Plexopathy
 Older people5
 Onset day to weeks
 Pain in anterior thigh with minimal sensory loss
 Reduced or absent knee flexion or knuckling of knee due to quadriceps weakness and atrophy
 Improves weeks to years, gradual recovery
 Compression syndrome
 Carpal tunnel syndrome, ulnar neuropathy at the elbow and peroneal neuropathy at the fibular head
 5-16% effected
 Retinopathy
 Loss or impairment of visions due to microcirculation to the eyes
 High chance of blindness, 86% if diagnosed before 30 years, 33% chance with those over 30 years
 Leading cause of adult blindness
- Problems Associated with Vascular Damage
 Cardiac problems
 Hypertension, heart disease and stroke
 Kidney disease
 Hand stiffness
 Limited hand and finger mobility and contractures
 75%
 Both flexor tenosynovitis and Dupuytren’s contractures
 Reflex sympathetic dystrophy
- Diabetes, Exercise and Massage
 Exercise has long-term benefits for improving hyperglycemia and may delay hypoglycemia
 Massage therapy has a similar effect to hypoglycemia
 Source of glucose should be made available during massage
 Massage effects anxiety and depression, whether a parents or C with diabetes
- Contraindications
 If a C with diabetes arrives for a treatment in a confused or lethargic state or exhibits changes in mental function, massage is contraindications
 Immediate referral to physician
 If a C has a hypoglycemia attack treat rapidly and discontinue massage
 If C loses consciousness, emergency care
 Care must be taken when doing slow, deep diaphragmatic breathing with those who have DM especially those susceptible to ketoacidosis
 Person many breath more rapidly
 May change insulin levels
 Consent from physician prior
 Caution for hypertension or cardiac complications
 Caution for peripheral nerve lesion or compression syndrome
 If decubitus ulcer or gangrene present, local and distal massage is contraindicated
 Tissue health of the feet should be checked
 Red or blistered areas from shoes pressure is the 1 st sign
 Deep cracks on heels contraindicate use of oil, may cause infection
 Caution with deep pressure techniques
 Friction or deep cross-fibre petrissage are contraindicated if tissue health is compromised or sensory loss is present
 Hydrotherapy extremes are contraindicated in light of possible decreased tissue health and sensory loss
 Avoid using eucalyptus oil, may lower blood sugar levels
- Massage Therapy
 Caution for complications or unstable or untreated DM
 Positioning according to C comfort
 May need help getting on and off the table
 C may experience faintness or postural light-headedness
 Appropriate hydrotherapy use, especially with complications
 If C’s insulin levels are stable, relaxation is appropriate treatment
 Stress can destabilize blood sugar levels
 Diaphragmatic breathing consult physician prior
 Improve circulation and drainage in the presence of unhealthy tissue and edema
 Especially feet and legs
 Elevate edematous limbs, pump nodules and perform lymphatic drainage
 Modify pressure if sensory loss or compromised tissue health
- Self-care
 Deep breathing, meditation and visualization are given
Hyperthyroidism
Hypothyroidism
Metabolic Syndrome
Metabolic Syndrome
- A group of problems that predict risk for type 2 diabetes and - Central obesity: apple rather than pear shape
cardiovascular disease - Asian Americans are at risk for complications with smaller abdominal measurement
Demographics - Other components are silent unless tested for
- Most don’t know - Diagnostic criteria:
- Risk increases with age and with body-mass index (BMI)  Any 3 of the identified features
Etiology Treatment
- 5 main features: - Short term goals:
 High fasting blood glucose:  Lower BG
 Over 100mg/dL after 9 hours of fasting, or needing  Correct cholesterol with diet, exercise, medication if necessary
medication to manage BG - Long term goals:
 Abdominal obesity:  Increase physical activity, lose weight
 Waist measure of 35”+ for women  Losing 5-7% of weight reduces the risk of complications by 60%
 Waist measurement of 40”+ for men  Exercise improves insulin action, decreases BG
 For Asian Americans: 32”+ for women, 35”+ for men  Quit smoking
 Elevated triglycerides  Limit alcohol use
 150 mg/dL or more for women Medications
 140 mg/dL or more for men - Metformin, insulin management
 Lower levels of high-density lipoproteins - Antihypertensive medications
 <50mg/dL or more for women - Cholesterol management drugs
 140mg/dL or more for men - Low-dose aspirin for antiplatelet activity
 Hypertension Massage Therapy Implications
 Systolic >130mmHg Risks: Risks depend on overall resilience and adaptability. Someone who exercises regularly will have better capacity than
 Diastolic >85mmHg someone who does not, or cannot. Be aware of where the client is in the arc of diabetes and heart disease
- Other possible features: Benefits: Massage therapy probably won’t change metabolic syndrome risk factors, but it can fit as a useful strategy for people
 High risk of blood clotting who are working on becoming healthier.
 H C-reactive protein, other indicators of inflammation
 Polycystic ovary disease
Thyroid Cancer
Urinary System Conditions

Kidney Disorders
Kidney Stones
Kidney Stones
Definition Types of Kidney Stones Treatment
- AKA: renal calculi, nephrolithiasis Calcium Stones - If a person can’t pass the stone…
- Crystals that develop in renal pelvis - Most common type made of calcium oxalate, calcium  Percutaneous nephrolithotomy
- Size varies phosphate  Closed surgery or application of ultrasound
 Grain of sand to the size of the whole kidney - Related to problems with calcium metabolism  Ureteroscopic stone removal
- If stones get lodged in ureter: ureterolithiasis Struvite Stones  Flexible tube up the urethra to remove the stone
Demographics - Composed of magnesium, ammonia from the ureters
- About 10% in US will have a kidney stone at some point - Associated with chronic urinary tract infections  Extracorporeal shockwave lithotripsy
- 500,000 emergency room visits/year - “staghorn calculus”  Sound waves break up the stone so it can be
- 2 million out-patients visits/year Uric Acid Stones passed
- Mostly in white or Asian men 20-50 years old - Associate with high meat and purine diets Prevention
 Can be others - Associated with increased risk for gout - Depends on the type of stones
- In US the “stone belt” crosses the southeastern region Cystine Stones  Removal of parathyroid glands
Etiology - Rare compared to others  Medication to help metabolism
- Tiny asymptomatic crystals in the kidney are called nidi - Related to genetic dysfunction with cystine metabolism  Dietary adjustments
- If a sizable stone moves into the urethra, pressure builds behind Other Stones  Adequate hydration
it - A very small percentage of kidney stones  Limit…
 Kidney swells, causing pain  Genetic problems with metabolism  Alcohol
- Most stones eventually pass without long-term damage  Use of proteases inhibitors for HIV/AIDS  Caffeine
 Some can cause kidney damage, lead to renal failure Signs and Symptoms  Oxalate-rich foods
- Most people who have 1 stone will have more - Most are totally silent, pass without pain Medications
 Each one increases the risk for kidney disease - If they get stuck or scrape the ureter… - For calcium, uric acid stones:
- Risk factors:  Kidney swell  Alkalizing agents to change pH in kidneys
 Congenital anomaly  Ureter bleeds (hematuria) and ureter contracts (renal - For chronic urinary tract infections and struvite stones:
 History of surgery, inflammation of GI tract colic)  Long-term antibiotics
 Urinary tract infections, blockages of urinary tract  PAINFUL - For cystine stones
 Diabetes - Pain…  Medication to bind cystine
 Has sudden on set - Analgesics
 Comes in waves Massage Therapy Implications
 Can cause nausea, vomiting Risks: A person who is passing a kidney stone should delay a
 Refers to groin massage therapy session until afterwards.
- Infection may also be present, with fever Benefits: A client who has fully recovered from kidney stones is a
good candidate for massage therapy.
Polycystic Kidney Disease
Polycystic kidney disease

Definition Autosomal Dominant Polycystic Kidney Disease Medications
- Inherited disorder - Need to inherit only 1 gene from 1 parent - Antihypertensives
- Genetic mutation in cells that form collecting ducts and tubules - More common, less severe than ARPKD - Analgesics (not NSAIDs)
Demographics - Often not evident until adulthood - Antibiotics if necessary
- Polycystic kidney disease (PKD) affects 600,000 in US  Hypertension, other symptoms develop in 30s and 40s Massage Therapy Implications
- Males = females Signs and Symptoms Risks: A person with impaired kidneys will have problems with fluid
- All racial groups are affected at the same rate - High hypertension in young adults management, high blood pressure, and the risk of secondary
- 5-10% of renal failure cases are linked to PKD - Reduction in urine concentration problems. His or her capacity for adaptation may be severely
Etiology - Chronic pain due to irritated kidney tissue limited. Any massage therapy offered in this context must allow for
- Genetic anomaly causes certain cells to proliferate - Headaches this, as well as for the likelihood of the use of powerful analgesics
- Form fluid-filled pockets on top of nephrons Treatment that may alter pain sensation.
- Kidneys become enlarged, but function is impaired - No treatment to correct genetic disorder Benefits: Massage therapy appear to temporarily drop blood
Complications - Goals: pressure. It may also help to allay some of the anxiety that
- High risk of renal failure  Control complications and symptoms inevitably accompanies living with a chronic and potentially serious
- Half of all patients become candidate for kidney transplant  Preserve kidney function disease. These benefits can be offered by a skilled clinician, as long
Types of Polycystic Kidney Disease - Manage pain, hypertension as the risks are accommodated
Autosomal Recessive Polycystic Kidney Disease - Needle aspiration of cysts Research: A rupture kidney cysts is in the medical literature as an
- Need to inherit a gene from each parent - Surgery if necessary adverse outcome from chair massage.
- Present at birth, seen with congenital hepatic fibrosis - Careful tracking for the possibility of transplant
- High risk of infant mortality
- More severe than ADPKD
Pyelonephritis
Pyelonephritis
Definition Types of Pyelonephritis Treatment
- Infection of the nephrons, renal pelvis Acute Pyelonephritis - Treat UTIs early to avoid pyelonephritis
- Often a complication of urinary tract infection - Severe symptoms, active bacterial attack - Antibiotic therapy – must be thorough
- May be related to other problems - Bacteria can invade capillaries, lead to blood poisoning - High risk populations need special monitoring
Demographics Chronic Pyelonephritis  Diabetes
- Infants, young children are vulnerable because of a structural - Usually related to incomplete treatment of UTI  Spinal cord injury
problem that is resolved later  Bacteria continues to grow and destroy kidney tissue  Kidney transplant recipients
 Up to 40% of UTIs in young children are related to this  Slow, and silent Medications
 UTI allows bacteria access to upper urinary tract  Risk of permanent damage, scar tissue, inflammation, - Antibiotics
- Acute pyelonephritis is diagnosed 250,000/year in US fibrosis Massage Therapy Implications
- Women > men, 5:1 - In infants, young children: due to vesicoureteral reflux Risks: Acute infections contraindicate most types of massage
Etiology  Structural anomaly at vesicoureteral valve therapy due to pain and risk of over-challenging a hard-working
- Simplest form:  Allows urine to back up to kidney system. Chronic infections pose less risk, but clinicians need to
 Urinary tract infection (UTI) moves up the ureters to Emphysematous Pyelonephritis know about a limited capacity for fluid management.
the kidney - Necrosis, gas-filled pockets within working cells Benefits: Soothing, gentle massage during a low-grade infection
 Pathogen is usually E. coli - Usually associated with uncontrolled diabetes may be supportive. Clients who have fully recovered are good
- More complex Signs and Symptoms candidates for massage therapy.
 Urethral blockage - Acute pyelonephritis:
 Pregnancy  Acute onset
 Diabetes  Begins with UTI, ascends the urinary tract
 Neurogenic bladder  Fever, nausea, vomiting
 Contaminated cystoscope or catheter  Burning, frequent urination
 By way of blood infection  Cloud, blood-tinged urine
 Back pain
- Chronic pyelonephritis:
 Usually subtle
 Silent while kidney damage accrues
Renal Cancer
Renal Cancer
Definition Types Renal Cancer Treatment
- Any type of cancer that begins in kidney tissues Renal Cell Carcinoma - Surgery
- Renal cell carcinoma (RCC) is most common - Most common form, 90% of all diagnoses - Arterial embolization
 AKA: renal adenocarcinoma, hypernephroma - Genetic and/or environmental triggers - Anti-angiogenesis drugs
Demographics - Several subtypes - Resist chemotherapy and biologic therapies
- About 64,000 diagnoses/year in US Transitional Cell Carcinoma Medications
 Men > women, 2:1 - Arises in renal pelvis - Chemotherapy if possible
- Average age at diagnosis = 64 - Essentially identical to bladder cancer - Biologic therapies if possible
 Can appear earlier, especially when linked to genetic  Same histological findings - Angiogenesis inhibitors
predisposition  Risk factors Massage Therapy Implications
- 14,000 deaths/year  Treatment options Risks: Treatment is aggressive and very taxing; the medications
- 20,000 renal cancer survivors now live in US Wilms Tumor have serious side effects that influence massage therapy choices,
Etiology - Rare type that affects young children including skin problems and hand-foot syndrome
- Kidneys are made mostly of epithelium (vulnerable to genetic - AKA: nephroblastoma Benefits: As long as risk related to both the cancer and its
mutation) - Usually found early, responsive to treatment: good prognosis treatments are respected, skilled massage therapy has many
- A layer of fat and a layer of connective tissue (Gerota fascia) Signs and Symptoms benefits to offer cancer patients, including reductions in pain,
wraps kidneys - Tends not to create symptoms until advanced anxiety, and depression, better sleep and appetite, improved
- In RCC, cells in the renal tubules lead to aggressive, vascularized  Blood in urine immune system function, and improved quality of life.
tumors  Mass in abdomen
 Especially serious if it penetrates Gerota fascia  Flank pain
 Metastasizes to lung, bones, liver  Unintended weight loss
- Risk factors:  Fever
 Genetic condition: von Hippel-Lindau syndrome  Fatigue
 Cigarette smoking  malaise
 Obesity - Symptoms can mimic polycystic kidney disease, pyelonephritis
 Hypertension
 Long-term dialysis
 Exposure to
 Cadmium
 Coke ovens
 Asbestos
Renal Failure
Renal Failure
Definition Types of Renal Failure Signs and Symptoms
- The kidneys are not functioning adequately Acute Renal Failure - Most systems are affected
 Could be acute or chronic - AKA: acute renal injury  Reduced urine output
Demographics  Kidney function suddenly drops to <50% of normal  Systemic and pulmonary edema
- Up to 10% of US adults are in some stage of renal disease - 3 categories  Arrythmia
 26 millions  Pre-renal problems: lack of adequate fluid volume  Osteomalacia
- Men > women  Bleeding, shock, blockage  Rashes, skin discoloration
- African Americans > whites, 4:1  Intrinsic problems  Lethargy, fatigue, malaise
- Better treatment options means the number of people with end  Infection, drug allergies, embolism  Headaches
stage renal failure (ESRF) are rising  Post-renal problems: fluid is prevented from leaving  Loss of sensation in hands and feet
 900,00 are being treated for ESRF  Kidney stones, benign prostatic hypertrophy,  Tremors, seizures
 570,000 are on dialysis tumors  Muscle cramps
 100,000 on transplant waiting list Chronic Renal Failure  Change in mental, emotional states
Etiology - AKA: chronic renal disease Treatment
- When the kidneys are over-taxed, functions are lost - Kidneys impairment accrues for months or years - For acute renal failure:
 Less EPO = anemia - Measured in term of glomerular filtration rate (GFR):  Restore renal blood flow for minimum damage
 Poor fluid management = - Stage I: GFR = 90mL/min or above - For chronic renal failure:
 Pulmonary and systemic edema - Stage II: GFR = 60-89mL/min  Control symptoms, prevent further complications, slow
 Cardiac tamponade - Stage III: GFR = 30-59mL/min progress
 Electrolyte imbalances - Stage IV: GFR = 15-29mL/min  Hypertension, diabetes control
 Leads to - Stage V: GFR = <15mL/min  Adjustment to salt, fluid intake
 Osteopenia Medications  Diuretics
 Poor digestion - Anti-hypertensives  Avoid NSAIDs
 Inflammation - Anti-diabetes medications  Dialysis
 arrhythmia - Diuretics Massage Therapy Implications
- kidneys can heal from short-term problems - Phosphate, potassium management drugs Risks: ESRF contraindicates any modality that demands a
- chronic, recurrent problems can cause scarring, i.e., - EPO-stimulating drugs substantial adaptive response. Clients undergoing dialysis are at
unsuccessfully treated… - Iron salts risk for infection at the site, and those who have received a kidney
 hypertension transplant are immune-suppressed.
 diabetes Benefits: Gentle massage therapy may be helpful and supportive
- Risk factors: for a person going through a difficult process.
 Age Research: Careful and limited massage appears to help with itching,
 Presence of diabetes and/or hypertension fatigue and depression for patients on dialysis.
 Other cardiovascular disease
 Obesity
 High cholesterol
 Lupus
 Any family history of kidney disease
Bladder and Urinary Tract Disorders

Bladder Cancer
Bladder Cancer
Definition Squamous Cell Carcinoma
- Growth of malignant cells in the urinary bladder - About 8% of all bladder cancer diagnoses in US
- Usually transitional cells - More common in developing countries with this parasitic, water-borne worm
 Urothelial carcinoma refers to cancer that begins in bladder or in transitional cells of renal Other Types of Bladder Cancer
pelvis, ureter, or urethra - Small cell carcinoma, adenocarcinoma of the bladder
Demographics - 1-2% of bladder cancer diagnoses in US
- #6 most common cancer in US Signs and Symptoms
- 75,000 diagnoses/year - Most dependable sign: painless blood in the urine
- 15,000 deaths/year  Visibly reddened or rust-colored
- Most often in whites, smokers - Later…
- Median age at diagnosis = 68  Signs related to invasion of or pressure on other tissues
- Men > women, 3:1  Bladder irritability
Etiology Treatment
- Constant, repetitive exposure to toxic chemical inside the urinary tract - Depends on stage at diagnosis
- Stimulates rapid replication at basal layer - Cystoscope + tools to remove abnormal tissue
 Easily disrupted by genetic mutations - Removal of bladder and nearby tissues
 Malignant growths cause bleeding into the bladder  Prostate
- Causes  Uterus, ovaries, etc.
 History of pelvic radiation - Removal of pelvic lymph nodes
 History of cigarette smoking  Risk of lymphedema in leg
 Chronic bladder infection - Radiation
 Bladder stones - Chemotherapy
 Catheter use - Biologic therapies
 One type of chemotherapy - Diligent follow-up care
 Parasite: Schistosoma haematobium Medications
- Most diagnoses are made early in the process - Chemotherapy agents, orally or via bladder wash
- Can grow in multiple locations at different speeds— - Biologic therapies via bladder wash
 Recurrence is very high Massage Therapy Implications
Types of Bladder Cancer Risks: Patients with bladder cancer are likely to undergo surgery soon after diagnosis, and they may
Transitional Cell Carcinoma have a variety of medical devices that require accommodation.
- Main focus of this discussion Benefits: As long as risks related to both the cancer and its treatments are respected, skilled massage
- Most common: about 90% of all bladder cancer diagnoses in US therapy has many benefits to offer cancer patients, including reductions in pain, anxiety, and
depression, better sleep and appetite, improved immune system function, and improved quality of life.
A client who has successfully treated bladder cancer is a good candidate for massage therapy.
Interstitial cystitis
Interstitial cystitis
- The urinary bladder becomes stiff, inelastic, irritated - Chronic pelvic pain
- Part of a group of bladder issues referred to as painful bladder syndrome or bladder pain syndrome - Pain and burning on urination
 May be connected to pelvic pains syndrome, a subtype of prostatitis when seen in men - Urinary frequency and urgency
Demographics - Painful intercourse
- Main target group is women around age 40 - Symptoms are exacerbated when bladder is full; eased when bladder is empty
- Seen in men and children too - Some have flare and remission; others do not
- No universally accepted definition of interstitial cystitis (IC) in relation to chronic pelvic pain Treatment
syndrome - Symptomatic relief, development of coping skills
- Some estimates suggest that it affects - Bladder distension, instillation
 1.2 million women  May be done with DMSO, which acts as an anti-inflammatory
 82,000 men - Lesions may be removed via cystoscopy
Etiology - Oral medication helps to restore bladder wall
- A healthy bladder can hold 8-12 oz. of fluid - Analgesics
 Lined with protective mucus - Smoking cessation
- IC occurs when protective mucus no longer shields the lining from acidity - Avoid acidic food and drinks
- Some people develop star-shaped lesions—Hunner ulcers - Surgery if necessary
- Muscular wall become fibrotic, capacity is lost Medications
- Bladder neck spasms - Medication to help build bladder lining
- Frequent, painful urination - Bladder distillation with DMSO or other medications
- Cause is not clear - Analgesics, antidepressants, anti-seizure drugs for pain management
- Could be autoimmune or allergy Massage Therapy Implications
- Could be pathologic thinning of mucous membrane Risks: IC has little risk for massage therapy as long as the client is comfortable.
- Unresponsive to antibiotics Benefits: Massage therapy may improve the quality of life for a person who lives with this challenging
- Could be neurologic: referred pain from trigger points in perineum condition.
- Some people with IC progress to a point where the pain signals are self-fulfilling: central Options: A client with an external bag for urine as a result of surgery may have special positioning
sensitization needs. Engage her or him to solve this problem for results. Gentle, sensitive touch to the lower
- As seen with fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome, others… abdomen may be helpful, if the client can tolerate it; plan to make it possible to interrupt the session
for trips to the bathroom if necessary.
Research: Manual therapies applied to the perineum show some positive effect on pain, urgency,
frequency; this is not in most massage therapists’ scope of practice, but it provides some interesting
information.
Urinary Tract Infection
Urinary tract infection

Definition Prevention of Urinary Tract Infection
- An infection anywhere in the lower urinary system - Drink lots of water, acidic juices
 UTI - Urinate when necessary; don’t hold it for later
 Bladder (cystitis) - Wipe from front to back after a bowel movement
 Urethra (urethritis) - Take showers rather than baths
Demographics - Empty the bladder after sex
- About half of all women have a UTI at least once - Avoid using feminine hygiene sprays or douches
- 6-8 million doctor visits/year in the US Signs and Symptoms
- Most common in women 20-40 years old - Painful, burning urination
- When a man has a UTI, it may be a sign of prostate problems or a sexually transmitted infection - Urinary frequency
Etiology - Reduced bladder capacity
- Foreign microorganisms are introduced into the urethra and bladder - Blood-tinged or cloudy urine
- 90% of UTIs are due to E coli: - Pelvic, abdominal, low back pain
 Harmless in the digestive tract, dangerous in the urinary tract - Men: pain in penis or scrotum
 Can be due to other pathogens Treatment
 Each may need a different antibiotic - Increased fluid intake for more frequent urination
- Almost all UTIs are in women - Hot/cold sitz baths
 Short urethra, close to anus - Antibiotics
- People who drain the bladder with a catheter are also vulnerable  Important to use the full prescription
- UTI can develop with repeated irritation, friction  Long-term low-dose antibiotics may be necessary
 “honeymoon cystitis” Medications
- Risk factors: - Antibiotics
 Spermicide use - Analgesics
 Diaphragm use Massage Therapy Implications
 Pregnancy (higher risk for complications) Risks: Infections may make clients uncomfortable receiving massage therapy; most will prefer to
 Diabetes reschedule
 Neurogenic bladder Benefits: Noninvasive massage therapy may be acceptable, especially after the infection has begun to
Complications subside. A client who has fully recovered from a UTI is a good candidate for massage therapy.
- Can complicate to pyelonephritis
- Chronic UTIs and accrued kidney damage can lead to renal failure
- Untreated infections may release bacteria into the blood: blood poisoning
Reproductive System Conditions

Disorders of the Uterus
Cervical Cancer
Cervical Cancer
- Growth of malignant cells in the lining of the cervix - Most cases are related to viral infection with human papilloma - Remove abnormal cells, watch for further changes
 Some abnormal cells are not dangerous virus (HPV) - Several options to remove dysplastic tissues
 Others are potentially aggressive and invasive  100+ varieties - In later stages:
Demographics  Some benign, some dangerous  Surgery
- US: 12,000 diagnoses/year; 4,000 deaths/year - Virus triggers cellular changes in lining of cervix  Radiation
- Worldwide: 500,000 diagnoses/year; 200,000 death/year;  Precancerous changes = dysplasia  Chemotherapy
mostly in countries with limited access to preventive health  Can occur with low-risk and high-risk viruses Medications
care options - Infection with low-risk virus: - Chemotherapeutic agents, if necessary
Types of Cervical Cancer  Dysplastic changes spontaneously resolve Massage Therapy Implications
Squamous Cell Carcinoma of the Cervix  The whole episode may be completely silent; she never Risks: Dysplasia has no specific risks for massage therapy; the risk
- Most common: 80-90% of all diagnoses knowns of working with a client who has advanced cervical cancer are
- Usually found on inferior aspect of cervix - Infection with high-risk virus: similar to the risks of working with any cancer patient: the
Adenocarcinoma of the Cervix  Cancerous cells grow in cervix possibility of metastasis and the challenges of treatment must be
- Rarer  Spread to uterus, vagina, pelvic cavity, and onward accommodated.
- Begins in mucus-producing cells at the superior aspect of the - HPV is sexually transmitted Benefits: As long as risks related to both the cancer and its
cervix  Skin-to-skin treatments are respected, skilled massage therapy has many
- Not associated with sexual activity - Risk factors in addition to exposure to HPV: benefits to offer cancer patients, including reductions in pain,
Other Types of Cervical Cancer  Many sexual partners, or few partners but they have anxiety, and depression, better sleep and appetite, improved
- Very rarely, other types of cancer can develop at the cervix: many partners immune system function, and improved quality of life.
 Melanoma  Smoking
 Lymphoma  3+ children
 Sarcoma  Overweight
Signs and Symptoms  Diet low in fruits and vegetables
- Early stages are silent  Being a des-daughter
- Later:  Co-infection with HIV and/or chlamydia
 Bleeding, spotting between periods, after menopause  Access to early detection and care
 Vaginal discharge - Vaccine:
 Pelvic, abdominal pain  Protects from HPV 6 and 11, 16, and 18; most but not
all aggressive forms of HPV
Cervical cancer screening is still necessary
Cervical cancer is the development of cancerous cells in the lining Early stages of cervical cancer are virtually silent; this disease is Risks: A woman with advanced cervical cancer must handle the
of the cervix. These may spread to affect the whole cervix, the rest detected by Pap (Papnicolaou) tests before symptoms develop. challenges of both the disease and its treatments. Any massage in
of the uterus, and other pelvic organs. Later signs and symptoms include bleeding or spotting outside a this context must respect those challenges.
normal menstrual period, vaginal discharge, and pelvic, abdominal Benefits: Most cases of cervical cancer are found before significant
pain. risks develop. Women in this situation who are receiving care, and
those who have successfully treated cervical cancer in the past, can
enjoy the same benefits from massage as the rest of the
population.
Dysmenorrhea
Dysmenorrhea
Definition Types of Dysmenorrhea Treatment
- Painful menstrual periods Primary Dysmenorrhea - Analgesics that inhibit prostaglandin secretion, narcotics if
- When a woman must limit activities or needs medication to - Starts within 3 months of menarche necessary
function for 1 day or more in each cycle - Factors include: - Hot or warm packs to the abdomen
Demographics  Excessive prostaglandin, vasopressin release - Exercise, stretching low back
- Leading cause of lost school and work time o These promote pain, inflammation, smooth - Low-dose birth control pills
- Up to 50% of all menstruating women at some time muscle contraction - Surgery, laparoscopy if necessary
- Frequency and severity seems to decline with age  Pain-spasm cycle of uterus contraction - Complementary approaches:
Etiology  Irritation to round and broad ligaments that anchor the  Vitamins B1, E, fish oil, magnesium, thiamine
- Menstrual pain is not a necessary part of having a menstrual uterus  Reduce fats, animal proteins, increase dietary fiber,
cycle Secondary Dysmenorrhea calcium
- Painful cramps can be a freestanding issue or a symptom of an - Complication of another pelvic disorder Medications
underlying issue - Contributors include: pelvic inflammatory disease; fibroid - Anti-inflammatories
- Emotional stress can exacerbate pain tumors; STIs; endometriosis; torsion of the ovary; ovarian cyst; - Analgesics
 Including the stress of anticipating a painful cycle pelvic adhesions, scar tissue from surgery or trauma - Low-dose birth control pills
Signs and Symptoms Massage Therapy Implications
- Often worse at the start of a period, then resolves Risks: Intrusive abdominal work while a woman is having cramps
 Dull aches in abdomen, low back may not be welcomed.
 Sharp pain and cramping in pelvis, abdomen Benefits: Massage therapy can be very helpful for dysmenorrhea
 Headaches both while a woman is in pain and as a strategy to reduce this
 Nausea, vomiting, diarrhea symptom with her monthly cycle
 Frequent urination Options: While the uterus seems to refer pain to the sacrum, work
- With secondary dysmenorrhea: on the sacrum and surrounding areas appears to reverse the circle,
 Symptoms may outlast period and gives relief to the uterus. When a woman with dysmenorrhea
 Flow may be irregular is not menstruating, specific work with her abdomen and pelvis
 Pain medication may not work may help improve function of her pelvic organs
 May be seen with infertility Research: Research suggests that massage with aromatherapy
appears to make a substantial difference in the experience of
menstrual pain
Dysmenorrhea is the technical term for menstrual pain that is The symptoms of dysmenorrhea are dull aching or sharp severe Risks: If extreme menstrual pain is being generated by an
severe enough to limit the activities of women of childbearing age. lower abdominal pain preceding and/or during menstruation. underlying problem, it must be identified before doing any
It may be a primary problem or secondary to some other pelvic Nausea and vomiting may accompany very severe symptoms. intrusive abdominal massage. Most women would probably also
pathology. Secondary dysmenorrhea may cause pelvic pain outside normal rather avoid deep abdominal work during their period.
periods as well. Benefits: Massage can have a profoundly positive affect for primary
dysmenorrhea, and it can be a helpful coping strategy for pain
caused by underlying problems.
Endometriosis
Endometriosis
- Cells from the endometrium are established elsewhere - First described in 1921 (James Sampson) - Goals:
- Begins in the pelvic cavity, may spread further  Hypothesis: growths escaped via retrograde flow  Relieve pain; stop progression; prevent new growths;
Demographics through uterine tubes restore fertility, if that is the patient’s wish
- Estimated that 8-10% of women of childbearing age may have - Now… - No permanent solution until post-menopause
this  Retrograde flow is still considered a factor - Analgesics
- Not all have symptoms - Hormone therapy
 Most women have some endometrial cells in the pelvis
- Higher incidence among women who had severe acne during - Surgery
during menstruation
adolescence Medications
Complications - Other factors: - NSAIDs or narcotics for pain, inflammation
- Dysmenorrhea  Coelomic metaplasia (metamorphosis of other cells - Oral contraception, other hormones to suppress ovulation
- Fibrosis and scarring that can cause infertility into endometrial cells) Massage Therapy Implications
- Risk of ectopic pregnancy  Endometrial cells are spread by surgery, laparoscopy Risks: Endometriosis may cause scarring, adhesions in pelvic cavity.
- Anemia  Can be spread by circulatory or lymphatic systems (only This requires special care and sensitivity for working in this area
- Uterine hyperplasia rarely found outside pelvic cavity) Benefits: This is a frustration, anxiety-producing condition.
- Can hide early signs of ovarian or endometrial cancer  Immune system suppression Massage therapy may help address those symptoms, giving the
Signs and Symptoms  Estrogen dominance client more tools to deal with this challenging situation
- Infertility - If endometrial cells colonize new tissues… Options: Special training in abdominal and pelvic massage therapy
- Premenstrual spotting may help for pain relief and better overall function for women with
 They stimulate angiogenesis
- Severe dysmenorrhea endometriosis
 They proliferate according to systemic hormonal
 Urinary urgency, painful urination, diarrhea, rectal Research: Massage therapy may help with pain control with
bleeding during menstruation commands endometriosis
- Painful sex - Growths cannot be shed with menstrual cycle
- Severity of pain does not correspond to severity of growths  They decay, stimulate inflammatory response
- Symptoms are worst during menstruation  Body builds cysts around them: endometriomas
 Many assume it is “just cramps”, miss an important - Growths look like…
diagnosis  Clear blisters early
 Black blood blisters later (“chocolate cysts”)
- Growths usually appear on…
 Ovaries; surface of peritoneum; behind uterus

Endometriosis is the implantation and growth of endometrial cells Endometriosis may have no symptoms. When it does, they Risks: If a client knows she has endometriosis, invasive abdominal
in the peritoneal cavity (and possibly elsewhere) that grow and generally include heavy, painful menstruation; pelvic and work must be done with extra case. Otherwise massage carries no
then decay with the menstrual cycle abdominal pain; difficulties with urination or defecation; painful specific risks for clients with this condition.
intercourse; and other problems, depending on which tissues are Benefits: Massage is unlikely to change the course of
affected. Symptoms are worst just before and during endometriosis but it’s generally soothing and calming effects can
menstruation. Infertility is a frequent complication of improve the quality of life for a woman who struggles with a very
endometriosis frustrating condition
Fibroid Tumors
Fibroid Tumors
- AKA: leiomyomas - Causes are not well understood - Usually none, unless they interfere with function
- Benign tumors that grow in and around the uterus  Appear in families - Hormone therapy shrinks them, but they grow back
- Can grow singly or in cluster  Stimulated by estrogen - Uterine artery embolization, followed by surgery
- Can be microscopic, or weigh several pounds  Disappears after menopause - Myomectomy to preserve uterus
Demographics  Probably a result of genetic + environmental + - Hysterectomy
- Very common hormonal factors Medications
- Up to 50% of all women - Histologically similar to keloid scars - Gonadotropin-releasing hormone inhibitors
- Lead to 200,000 hysterectomies/year  Both keloids and fibroids are most common in black - Progesterone, progestin
Complications women Massage Therapy Implications
- Heavy periods, anemia - The distortion they cause may trigger changes in extracellular Risks: It is best not to disrupt a known tumor with intrusive pelvic
- Infertility matrix that makes them bigger massage; no other specific risks apply to this condition.
- Problems with late-stage pregnancies - Classified by location: Benefits: Massage therapy has no direct impact on fibroids. Most
- Pedunculate fibroids can twist (torsion)  Submucosal: under mucous lining of uterus clients with an uncomplicated version of this condition can enjoy
 Cuts off blood supply  Intramural: within muscular wall all the benefits that massage therapy has to offer.
 Tissue dies  Subserosal: on superficial aspect of uterus
Signs and Symptoms
- Usually completely silent
- Symptoms if the tumor interferes with function or causes pain
- Usually grows slowly, but can grow quickly
- Need to rule out uterine cancer
Fibroid tumors are benign growths in the muscle or connective Fibroid tumors are often asymptomatic. They may cause heavy Risks: Massage carries little risk for a client with fibroid tumors
tissue of the uterus menstrual bleeding or put mechanical pressure on other structures unless a tumor is very large and massage is deep, intrusive, and
in the pelvis low in the pelvis.
Benefits: Massage is unlikely to have any effect on fibroid tumors.
Clients with this condition can enjoy the same benefits from
bodywork as the rest of the population.
Uterine Cancer
Uterine Cancer
- Development of cancerous cells in the uterus - For post-menopausal patients: - Hysterectomy
- Classified as…  Vaginal bleeding or spotting is a dependable sign  Ovaries, uterine tubes too
 Endometrial cancer  Often found in Stage I or II - Radiation, hormone therapy
 Uterine sarcoma - For younger women: spotting between periods - Lymph nodes at groin are dissected
Demographics - For all women: - Chemotherapy
- Diagnosed in 40,000/year in US  Vaginal discharge; pelvic pain, pain with sex; pelvic - Uterine-sparing techniques are possible; high rate of
- 7,500 deaths/year mass; change in bowel, bladder habits; unintended recurrence
- #4 most common metastatic cancer in women weight loss Medications
- Usually found early, with a good prognosis Types of Uterine Cancer - Chemotherapeutic agents
Etiology Endometrial Cancer - Hormone therapy
- Begins with mutation in affected cells - Most common type, several subtypes Massage Therapy Implications
 Usually endometrium  Adenocarcinoma: Risks: Uterine cancer is treated with combinations of surgery,
 Can be muscle or connective tissue cells o Most common of endometrial cancers; cells chemotherapy, radiation, and hormones. Massage Therapy in this
- Main trigger: exposure to estrogen resemble normal cells, not usually aggressive context must accommodate for these challenges.
 Endogenous; Exogenous  Adenosquamous carcinoma: Benefits: As long as risks related to both the cancer and its
- Other factors: o Squamous cells and endothelial cells treatment are respected, skilled massage therapy has many
 Race; age; history of other cancers  Papillary serous carcinoma: benefits to offer cancer patients, including reductions in pain,
- New growths are fragile, friable o Rare, potentially aggressive anxiety, and depression, better sleep and appetite, improved
 Leads to vaginal bleeding, spotting  Clear cell adenocarcinoma: immune system function, and improved quality of life
 In postmenopausal women = most dependable sign o Rarest, potentially aggressive Research: Lymphedema of the legs is a common complication of
- Can metastasize through 4 routes: Uterine Sarcoma uterine cancer treatment. Specialized massage techniques have
 (1) Circulatory system (2) Lymphatic system (3) Direct - Originates from non-glandular tissues been shown to be effective to control symptoms.
contact (4) Peritoneal fluid  Often more aggressive, poorer survival rate than
Risk Factors endometrial cancers
- Age (almost always over 50)  Stromal cell cancer:
- Race (most common in white women, more serious in black o Affects connective tissue of uterus
women)  Leiomyosarcoma:
- Genetic profiles associated with colorectal and breast cancer o Starts in smooth muscle cells of uterus
- Type 2 diabetes  Mixed Mullerian sarcoma:
- Obesity o Combines features of adenocarcinomas and
- Sedentariness sarcomas
Uterine cancer is the development of cancerous cells in the The most dependable symptom of uterine cancer is Risks: The risk for uterine cancer patients who wish to receive
endometrium or other tissues of the uterus postmenopausal spotting or bleeding. Other signs can include massage or bodywork are the same as those for other cancer
spotting between periods for premenopausal women, vaginal patients: both the challenges of the disease and of its treatments
discharge, pelvic pain, pain with sex, and unexplained weight loss. must be respected. For uterine cancer this can involve
chemotherapy, radiation, and surgery.
Benefits: if bodywork accommodates for the limitations brought
about by uterine cancer and its treatments, the benefits it can
offer include decreased pain and anxiety, increased appetite and
exergy, improved sleep and less depression.
Disorders of Other Female Reproductive Structures

Breast Cancer
Breast Cancer in Brief

Definition Prevention Signs and Symptoms
- Development of tumors in the epithelial or connective tissues - Can’t be prevented - Early symptoms are subtle (lots of room)
of the breast - Can be found early  Self-exam may find changes in texture earlier than
- May start as non-malignant, become invasive later  Self-examination other tests
Demographics  Clinical breast exam - Advanced:
- 230,000 diagnoses in women/year in US  Mammograms, other imaging techniques  Asymmetrical breast growth
- 2,300 diagnoses in men o Mammograms are not definitive  Inverted nipples with discharge
- Does not include 62,000 findings of “in situ” cancer o “All clear” from mammogram may not be  “Orange peel” texture at breast
- 41,000 deaths/year for women reliable  May cause symptoms elsewhere
- 500 deaths/year for men Types of Breast Cancer Treatment
- 2.5 million breast cancer survivors alive today in US Ductal Carcinoma - Determine stage, risk of metastasis with sentinel node biopsy
Etiology - Most common type, 70-80% of all diagnoses - Surgery
- Malignant cells can grow in all breast tissues - Can occur in situ (only epithelial lining of ducts is affected) - Radiation
 Most begin in epithelium - Can become invasive - Chemotherapy
- Many types of breast cancer start as benign in situ growths Lobular Carcinoma - Hormone therapy
 Take on malignant characteristics later - About 5-10% of all diagnoses - Biologic therapy
- Cells from growing tumors may invade circulatory lymph - Can be in situ Medications
system - Significant risk of becoming invasive - Chemotherapeutic agents
 Proximity of lymph nodes is key - High incidence of being bilateral than ductal carcinoma - Hormone therapy
- Metastasis to lymph nodes first Inflammatory Breast Disease - Biologic therapy
 Then to liver, lungs, brain - Relatively rare in US - Bisphosphonates, antiemetics to limit complications of cancer
 Can also cause: Bone fractures, pleural effusion, - Resembles as insect bite: and treatment
bronchial obstruction  Inflamed, itchy, red skin Massage Therapy Implications
Risk Factors Other Types of Breast Cancer Risks: As with other cancers, the risks of massage therapy for
- No predictable profile of breast cancer patient - Collectively = 5-10% of all diagnoses breast cancer patients includes possible access to tumors, unstable
 Most women with risk factors will NOT develop breast  Paget disease of the breast affects the nipple, looks like bones, compromised organs, and surgical equipment.
cancer eczema Benefits: As long as risks related to both the cancer and its
- Age (mostly over 50)  Medullary carcinoma = rare malignancy of connective treatments are respected, skilled massage therapy has many
- Prolonged estrogen exposure tissue benefits to offer cancer patients, including reductions in pain,
- More than 1 alcoholic drink/day  Tubular carcinoma refers to shape of tumor cells anxiety, and depression, better sleep and appetite, improved
- History of radiation to the chest  Mucinous carcinoma: rare, with a good prognosis immune system function, and improved quality of life
- History of lobular carcinoma in situ Research: Studies on massage therapy for breast cancer have
- Presence of BRCA1, BRCA2 yielded evidence on how massage therapy impacts mood, pain,
 These account for 5-10% of patients nausea, fatigue, and many other symptoms and side effects. Still,
 90%+ patients are NEGATIVE for this genetic anomaly the risk for bias is high, and there is still much to discover with
rigorously conducted research.
Breast cancer is the growth of malignant tumor cells in breast The first sign of breast cancer is a small painless lump or thickening Risks: Breast cancer patients undergo treatments that are
tissue. These cells can invade skin and nearby muscles and bones. in the breast tissue or near the axilla. The lump may be too small to extremely taxing on general health as well as on physical and
If they invade lymph nodes, they can metastasize to the rest of the palpate, but may show on a mammogram. Later the skin may emotional well-being. Ports or other surgical equipment may be
body. change texture, the nipple may change shape, and discharge may present. Further, this cancer can invade the skeleton, leading to
occur. unstable and easily fractured bones. Any bodywork in this context
must respect all these challenges.
Benefits: As long as the challenges of both breast cancer and its
treatments are accommodated, massage can be a wonderful,
supportive, important coping mechanism for many patients.
Ovarian Cancer
Ovarian Cancer
Definition Types of Ovarian Cancer Treatment
- Growth of malignant tumors on the ovaries Adenocarcinoma of the Ovary - Surgery
- Several subtypes, mostly beginning in epithelial cells - About 90% of all cases  Oophorectomy, may take parts of large and small
Demographics - Several subtypes with varying growth patterns intestine
- 24,000 diagnoses in women/year in US - Some types aggressively invade pelvic, abdominal organs - Chemotherapy
- 14,000 deaths/year without early symptoms  At home, intravenously, or directly into the
- Higher mortality rate than many types of cancer Germ Cell Ovarian Cancer peritoneum
Etiology - Rare tumors, usually in women under 30 - Radiation
- Ovaries are composed of cells most vulnerable to DNA - Several subtypes  As adjunctive therapy
mutation - Prognosis is usually good Medications
- Ovaries are located in a way that allows metastasis through all Stromal Cell Ovarian Cancer - Chemotherapeutic agents
4 routes: - Tumors can be benign or malignant - Biologic therapies (not yet a common option for ovarian
 Blood; lymph; direct contact; peritoneal fluid - Grow in connective tissue, hormone-producing cells cancer)
- Risk factors  Symptoms suggest overproduction of estrogen and/or Massage Therapy Implications
 Family history: a woman with a 1st degree relative with testosterone Risks: Ovarian cancer treatment has many possible side effects; be
ovarian cancer has a 1:3 chance of developing it as well - Prognosis is usually good sure to work with the health care team to make appropriate
o Also in families with history of breast or Signs and Symptoms accommodations
colorectal cancer - Early signs are extremely subtle, easy to miss Benefits: As long as risk related to both the cancer and its
 Reproductive history: women who never have a break  Feeling of heaviness in pelvis treatments are respected, skilled massage therapy has many
in their menstrual cycle are at increased risk  Vague abdominal discomfort benefits to offer cancer patients, including reductions in pain,
o Supports the theory that ovarian cancer is o Bloating, nausea, diarrhea, constipation anxiety, and depression, better sleep and appetite, improved
linked to repetitive ovarian trauma, i.e.,  Urinary frequency, urgency immune system function, and improved quality of life
ovulation  Vaginal bleeding Research: Massage therapy has been seen to positively impact self-
 Hormone replacement therapy, especially with  Change in menstrual cycle perceived hopelessness for ovarian cancer patients; this
unopposed estrogen for 10 years or more  Weight gain or loss characteristic can significantly improve a person’s ability to
 Other: exposure to radiation, asbestos, use of talcum - Later… tolerate treatment and preserve quality of life
powder on the genitals, high-fat diet, endometriosis,  Palpable abdominal mass
age  Increased abdominal girth
 Ascites
Ovarian cancer is the development of malignant tumors on the Symptoms of ovarian cancer are generally subtle until the disease Risks: As with all cancers, the risks of massage for ovarian cancer
ovaries that may metastasize to other structures in the pelvic or has progressed to life-threatening levels. Early symptoms include a patients depend on both the cancer and the treatments the
abdominal cavity feeling of heaviness in the pelvis, vague abdominal discomfort, patient is using. Ovarian cancer patients usually undergo
occasional vaginal bleeding, and weight gain or loss. aggressive therapies, so their overall resilience is often extremely
challenged.
Benefits: As long as accommodations are made for surgery,
chemotherapy and other interventions, bodywork can be a useful
intervention for anxiety, insomnia, pain and depression during an
extremely trying, and often life-threatening process.
Ovarian Cysts
Ovarian Cysts
Definition Types of Ovarian Cysts Signs and Symptoms
- Any cyst that grows on the ovaries Follicular Cysts - Usually silent until the cyst is injured in some way
- Cysts connected to ovulation may be called functional cysts - Most common type of ovarian cysts - Possibly…
Demographics - A follicle holding a mature egg doesn’t rupture completely  Possible dull ache on affected side
- Most women will have an ovarian cyst at some point  A blister forms over the follicle and egg  Painless swelling in pelvis
- Functional cysts are typically benign and self-resolving  Happens before ovulation  Pain with intercourse
- 5-7% of women of childbearing age have polycystic ovarian - Rarely bigger than 2-3”  Or, nothing without complications
syndrome - Receded within a month or two Treatment
- Ovarian cancer can begin as a cyst Corpus Luteum Cysts - Functional cysts: watchful waiting
Etiology - Blisters form over the site of egg release (corpus luteum) - Oral contraceptives to alter hormone secretion, prevent new
- In a normal menstrual cycle, a follicle develops and then  Hormone secretion is blocked cysts
rupture, releasing an ovum  Happens after ovulation - Surgery if necessary
- If the follicle doesn’t rupture completely, a follicular cyst forms - Can delay subsequent ovulations Medications
- If the ruptured follicle seals up behind the ovum, important - Can create symptoms that mimic pregnancy - Oral birth control
hormones are trapped: this is a corpus luteum cyst - Usually resolve within a month or 2 - Luteinizing hormone analogs for polycystic ovary syndrome
- Risk factors - Can be more dangerous than follicular cysts: a risk of rupture - Anti-androgenizing hormones if oral contraceptives are not
 Estrogen dominance (?) and bleeding successful
 Hypersensitivity to gonadotropin-stimulating hormone Polycystic Ovaries Massage Therapy Implications
 Infertility treatments - Enlarged ovaries with multiple small cysts Risks: Ovarian cysts contraindicate intrusive abdominal massage.
Complications  These are immature follicles; they don’t ovulate They can be large and easy to rupture, which can cause bleeding or
- Cysts can grow big enough to interfere with local blood flow - Causes change in hormone cycles a risk of peritonitis. Clients with polycystic ovaries may also be at
- They can put pressure on the bladder  Loss of menstruation; acne; facial and body hair; poor risk for other conditions that influence massage therapy choices.
- They can grow very large insulin sensitivity; risk of metabolic syndrome, diabetes Benefits: Massage therapy is unlikely to improve a person’s ovarian
- They may twist on a stalk (torsion) and heart disease cysts, but if it is done safely it can improve the quality of life for a
- Degeneration of a cyst can cause peritonitis Endometriomas woman who lives with this situation. A client who has fully
- Their symptoms mimic ovarian cancer - Pockets of endometrial cells recovered from an ovarian cyst carries no related cautions for
- Complication of endometriosis massage therapy.
- “Chocolate cysts”
Dermoid Cysts
- AKA: teratomas
- Some primitive cells have been isolated, grow into various
tissues
 Teeth, hair, bone fragments, etc.
- Usually harmless in women
- In men they can signal a dangerous form of testicular cancer
Most ovarian cysts are fluid-filled growths on the ovaries. Some Ovarian cysts may have no signs or symptoms, or they may cause a Risks: Diagnosed ovarian cysts contraindicate intrusive abdominal
types of cysts are associated with ovarian cancer, but the cysts disruption in the menstrual cycle. Constant or intermittent pain in massage, which could cause them to rupture and bleed. A client
considered in this discussion are benign. the pelvis, pain with intercourse, or symptoms similar to early with painful symptoms of ovarian cysts that persist for more than a
pregnancy may arise from some ovarian cysts few days would be well-advised to get a formal diagnosis.
Benefits: Massage has no specific benefits for ovarian cysts. A
client with this condition can enjoy the benefits of any bodywork
that does not threaten to mechanically disrupt a cyst, and clients
who have had cysts in the past with no current symptoms can
receive massage or bodywork without restrictions.
Disorders of the Male Reproductive System

Benign Prostatic Hyperplasia
Benign Prostatic Hyperplasia

- The prostate gland grows new cells, becomes enlarged - Difficulty with urination - Only treated if it causes problems
- It is NOT prostate cancer (but the 2 may overlap)  Bladder becomes stiff and irritable - Medications to limit prostate growth
Demographics  Urinary tract infections  Side effects may be substantial
- 50% of men over 60  Pyelonephritis - Surgery to relieve pressure on urethra
- 70% of men over 70  Bladder stones  Many options, minimally invasive
- 80% of men over 80… Etiology Medications
- Many do not experience significant symptoms - Prostate gland starts small - Hormones to alter prostate cell behavior
Signs and Symptoms  Grows in puberty - Alpha-blockers to relax smooth muscle tissue, improve urinary
- Difficulties with urination  May grow again around age 40-50 symptoms
 Weak flow - Possible triggers: Massage Therapy Implications
 Interrupted flow  Formation of dihydrotestosterone Risks: Watch for signs of BPH complications, especially urinary tract
 Frequency  Estrogen exposure infections. Otherwise, massage therapy carries no specific risks for
 A feeling that the bladder is never empty - Prostate can put mechanical pressure on urethra clients with BPH
 Leaking, dribbling  Wrapped in fascial capsule that limits outward Benefits: Most bodywork is safe and appropriate for men with BPH
 Possible acute urinary retention – medical emergency expansion if they are comfortable; massage therapy outside the abdomen is
 Affected tissues are usually deep, next to urethra unlike to affect the prostate in any way
 (These features help to distinguish BPH from prostate Options: Clinicians knowledgeable about work in the pelvis may be
cancer) able to improve symptoms of BPH with careful work in this area. It
 Extend of enlargement does not correspond to is vital to have ruled out prostate cancer before undertaking this
symptom severity
Benign prostatic hyperplasia (BPH) is a condition in which the The primary symptoms of BPH have to do with mechanical Risks: Bodywork has no particular risks for men with BPH as long as
prostate gland of a mature man begins to grow for the first time obstruction of the urethra. This leads to problems with urination, they are free from urinary tract infection or kidney disorders
since the end of puberty. It is not related to cancer, which is why including a feeling of urgency, difficulties with initiating flow, Benefits: Bodywork is unlikely to have a directly positive effect on
this condition is called “benign”. leaking, and the sensation that the bladder is never emptied. BPH, but as long as they are comfortable on the table, clients with
Obstructions may also raise the risk of urinary tract infection or this condition can enjoy the same benefits from massage as the
kidney irritation. For many men however, BPH is a silent condition. rest of the population.
Prostate Cancer
Prostate Cancer
- Growth of malignant cells in the prostate gland - Cancerous cells in the prostate can put pressure on the urethra - Depends on stage, type
- Often grows slowly, but can be aggressive  Mimics benign prostatic hyperplasia (BPH)  Watchful waiting
- Metastasizes, usually to bladder, rectum, pelvic bones  Easy to ignore in early stages  Radiation
Demographics - Often grows slowly o Internal pellets, external beams, protons
- 233,000 diagnoses/year  Can stay silent long enough to metastasize before  Surgery
- 29,000 deaths/year detection  Hormone therapy
 #2 cause of death by cancer for men in US - Main red flags for prostate cancer risk found in biopsies:  Chemotherapy
- 5-year survival rate 98.9%  Prostatic intraepithelial neoplasia  Biologic therapies
- 2.5 million prostate cancer survivors alive today in US o Low grade  Diet, exercise
- Mostly in men over 65 o High grade - In elderly men…
 Rare in men under 40 o Proliferative inflammatory atrophy  May opt not to treat to preserve quality of life
- More common and more serious in black men than in others - Triggers, risk factors Massage Therapy Implications
Signs and Symptoms  (Unknown) Risks: Massage therapists who have older male clients will
- Similar to BPH  MUST have access to testosterone probably encounter this disease. Any massage therapy must
 Enlarged prostate  Genetic predisposition for some accommodate for age and disease-related frailty and resilience.
 Obstruction of the urethra Medications Further, brachytherapy requires the delay of massage therapy until
- Pain while urinating - Hormone therapy the radioactive pellets have been removed.
- Pain with ejaculation - Analgesics Benefits: As long as risks related to both the cancer and its
- Erectile dysfunction - Bisphosphonates for bone density treatments are respected, skilled massage therapy has many
- Low back pain (sign of bone or nerve involvement) - Chemotherapeutic agents benefits to offer cancer patients, including reductions in pain,
- PSA test signs - Biologic therapies anxiety, and depression, better sleep and appetite, improved
 (This is complex and not necessarily definitive) immune system function, and improved quality of life
Prostate cancer is the growth of malignant cells in the prostate The symptoms of prostate cancer include problems with urination: Risks: Massage for prostate cancer patients, as with all cancer
gland, which may metastasize, usually to nearby bones or into weak stream, frequency, urgency, nocturia, all arising from patients, must be gauged to the constitutional health and
pelvic or inguinal lymph nodes constriction of the urethra. Later symptoms include blood in the resilience of the client. Accommodations for both disease, which
urine, painful ejaculation, and persistent bone pain. may lead to bone damage, and for the treatments, which can
involve anything from chemotherapy to radiation to surgery, must
be individualized for each client.
Benefits: As with all cancer patients, massage that respects both
the disease and the challenges presented by treatment can be an
effective strategy for managing pain, insomnia, depression,
anxiety, and many other complications related to this challenging
disorder.
Prostatitis
Prostatitis
Definition Types of Prostatitis Treatment
- The prostate becomes painful, possibly inflamed - Examination of prostate secretions gives clues for what type is - Type 3 (CPPS) may be treated with “just in case” antibiotics,
- Sometimes connected to an infection; often not present then by symptoms
Demographics Type 1: Acute Bacterial Prostatitis  Alpha-blockers
- Most common prostate problem in men under 50 - Acute infection  Anti-inflammatories
 Up to 50% of men will have symptoms at some point  May involve abscesses  Frequent ejaculation
- 2 million visits to urologists/year  May require surgical intervention  Sitz baths
Etiology  Most common agent is E. coli  Self-massage of perineal trigger points
- Draining channels for prostate secretions are on a horizontal Type 2: Chronic Bacterial Prostatitis  Biofeedback training
plane around the outside of the organ - Recurrent, low-grade infection Medications
 If not frequently expelled, contents can become  Most common agent is E. coli - Antibiotics
irritating Type 3: Chronic Nonbacterial Prostatitis or Chronic pelvic pain - Anti-inflammatories
 Bladder reflex can also irritate the prostate syndrome (CPPS), prostadynia - Alpha-blockers
 Prostate stones may develop - 3a: Inflammatory CPPS - Anti-anxiety medication for chronic pain
 Acute or chronic infections may develop  WBCs are found in prostate secretions Massage Therapy Implications
Signs and Symptoms - 3b: Noninflammatory CPPS Risks: Acute infection and fever contraindicate any but the gentlest
- Type 1 (Acute infection) looks like urinary tract infection  No WBCs found in prostate secretions massage therapy
 Pain, burning with urination; frequency, urgency  Most common type of prostatitis (misnomer – this is Benefits: Massage therapy probably won’t directly affect prostate
 Pain in pelvis, perineum, testicles, penis painful, but not evidently inflammatory) pain, but it can help to address the stress and anxiety that
 Penile discharge, painful ejaculation, erectile  No specific causative factor identified accompanies having a long-term, painful disorder
dysfunction, low back pain, fever  Theories: Options: Most massage therapists cannot work the perineal
 Prostate is palpably hot (through the wall of the o Unidentified bacteria muscle, but knowing that this condition may have a myofascial
rectum) o Referred pain from perineal trigger points component can help us to help out clients find effective treatment
- Type 2 (Chronic infection) Type 4: Asymptomatic Inflammatory Prostatitis Research: In a trial that compared patients with CPPS who received
 Same symptoms, less severe - No subjective symptoms massage therapy to those who received manual therapy to the
- Type 3 (CPPS) - WBCs are found in prostate secretions or tissue perineal muscle, both groups had improvement, but the group that
 Same symptoms without fever, discharge, heat received perineal massage had greater results for a longer period
- Type 4 of time.
 Asymptomatic
Prostatitis is inflammation or irritation of the prostate gland, either Symptoms of prostatitis vary according to their cause. Acute Risks: A person with an acute bacterial infection of the prostate is
from pathogenic or nonpathogenic causes prostatitis involves fever, extremely painful urination, urinary unlikely to seek massage before other types of care, so it is unlikely
frequency and urgency, and pain in the penis, testicles, perineum, that a massage therapist or bodywork practitioner will have a
and low back. Chronic prostatitis has similar signs and symptoms, client with fever, malaise and debilitating pelvic pain. If that does
but they tend to be less severe, and they may not include fever. occur, gentle non-invasive work and a recommendation to consult
a primary care provider are the best options.
Benefits: A person who has chronic condition with no acute signs
of infection may receive massage without risk, as long as he is
comfortable on the table.
Testicular Cancer
Testicular Cancer
- Growth of malignant cells in the testes - Painless lump on the testicle - Surgery to remove affected testicle, secondary tumors
- Usually grow slowly, but can metastasize through blood and - Feeling of fullness in the scrotum - Radiation for seminomas
lymph too: bones, liver, lungs and brain - Dull ache in low abdomen, groin - Chemotherapy if necessary
Demographics - Enlargement, tenderness of breasts - Possible removal of inguinal lymph nodes
- Diagnosed about 8,800 times/year in US - (Any of these that last 2 weeks needs a doctor visit) - Follow-up care to watch for further metastasis
- 440 deaths/year - Later symptoms indicate sites of metastasis Medications
- Highly treatable Types of Testicular Cancer - Chemotherapeutic agents
 95% are alive at 5 years after diagnosis Germ Cell Tumors Massage Therapy Implications
 230,000 testicular cancer survivors in US today - Arise within sperm and hormone-producing cells of testis Risks: Massage therapy must be accommodated for cycles of
- Mostly in white men 20-55 years old  Seminomas: radiation and/or chemotherapy
 Can be in any race, any age o Most common type of testicular cancer, 40- Benefits: Testicular cancer patients are often encouraged to
- Diagnostic rates have been climbing in US and other developed 50% of diagnoses exercise; this is a sign that massage therapy is probably safe and
countries o Grows slowly appropriate. Focus helping with pain, anxiety, depression, and
 Could be related to exogenous estrogen exposure o Highly sensitive to radiation, very treatable other secondary symptoms related to cancer and cancer
Etiology  Non-seminomas: treatments.
- Begins with mutation to fast-growing cells o Several subtypes: Embryonic carcinoma; yolk
- Risk factors sac tumor; choriocarcinoma (most aggressive,
 Cryptorchidism; congenital abnormalities; age; race; poorest prognosis)
history of testicular cancer; HIV+ Stromal Cell tumors
- Growths within supportive, connective tissue of testis
- Very rare: <5% of all diagnoses
Testicular cancer is the growth of malignant cells in the testicles, Early signs of testicular cancer include a painless lump in the Risks: The risks of bodywork for a client with testicular cancer are
which may metastasize to the rest of the body scrotum, a dull ache in the low abdomen or groin, a sense of the same as those for other cancers: the challenges presented by
heaviness in the scrotum, and enlarged or tender breasts. both the disease and its treatments must be accommodated.
Because this type of cancer if often very treatable, patients may be
more resilient and less fragile than some other cancer patients
Benefits: As long as bodywork is within a client’s tolerance for
adaptation, massage for testicular cancer patients can be a helpful
too to deal with some of the common complications of cancer in
general: anxiety, pain, depression, insomnia, and poor appetite.
Other Reproductive System Conditions

Menopause
Menopause
- The moment the ovaries stop producing enough hormones to - Ovaries secrete a variety of hormones - Hormone replacement therapy
initiate a menstrual cycle  Under direction of follicle-stimulating hormone (FSH)  Estrogen + progesterone for women who have a
 Not identified until a full year after the last cycle and luteinizing hormone (LH) from uterus
- Leading up to this moment = perimenopause pituitary/hypothalamus  Can reduce risk of osteoporosis, colorectal cancer
- NOT A DISEASE - As they age, ovaries become less sensitive  Can increase the risk of other problems
 But it is a condition that changes the way we function  FSH goes up but estrogens, progesterone go down - Other medications to mitigate symptoms
 It can cause several symptoms that impact quality of  Stops the process of preparing for pregnancy - Herbal preparations
life  No more ovulation, no more menstruation  Black cohosh, red clover, dong quai, ginseng, wild yam,
Demographics - Other tissues targeted by ovarian hormone kava (not risk free: some interactions can be
- Average age for onset of perimenopausal symptoms = 47.5  Bones: estrogen inhibits osteoclasts; progesterone dangerous)
- Average age at which transition is final = 51.4 stimulates osteoblasts (women can lose 20% of bone Medications
- About 46 million women in US are postmenopausal mass in 1st year) - Hormone replacement therapy
 Will be 50 million by 2020  Cardiovascular health: premenopausal women have - Herbal preparations
Signs and Symptoms of Perimenopause higher HDLs than others; postmenopausal woman have - Statins, other cardiovascular disease medications
- Related to changes in hormone secretions cholesterol profiles that are similar to men (increased - Bisphosphonates for bone density if necessary
 Hot flashes (power surges) risk of heart disease) Massage Therapy Implications
 Night sweats  Protection from some types of cancer: high Risks: A heathy woman going through perimenopause has no
 Insomnia estrogen/progesterone appears to decrease risk of particular risks or cautions for massage therapy
 Mood swings colorectal cancer and increase risk of breast, ovarian Benefits: Massage therapy can be a wonderful addition to the life
 Urinary urgency cancer of a woman going through this transition
 Loss of urinary continence  Central nervous system function: estrogen linked to Research: Massage therapy has shown good results for
 Decreased sex drive mood, depression, cognitive function; supplementing perimenopausal symptoms including insomnia, anxiety,
 Vaginal dryness can help with mild depression insomnia, short term depression, and general quality of life. One study suggested that a
 Confusion, short-term memory loss, poor memory problems specific modality may also help to improve bone density: an
concentration - After menopause the estrogen/progesterone balance is lost exciting finding that needs to be investigated.
- “Genitourinary syndrome of menopause” = changes in sex - Estrogen dominance can exacerbate imbalance
drive, vaginal dryness, urinary discomfort
Menopause refers to the moment when ovaries no longer respond The symptoms associated with a decline in ovarian function Risks: Massage has no particular risks for a healthy woman who is
to chemical signals to establish a reproductive cycle. Although this (perimenopause) include night sweats, hot flashes, insomnia, going through the changes leading up to menopause.
usually happens as a normal part of aging, menopause can be mood swings, decreased sex drive, vaginal itchiness or dryness, Benefits: Massage is unlikely to alter the course of perimenopause,
induced through surgery, radiation, or medication urinary incontinence, and poor concentration and memory. but it can be a powerfully positive experience for a woman
Longer-term changes include an increased risk of osteoporosis and undergoing fundamental changes in her self-identity and physical
cardiovascular disease processes.
Pregnancy
Pregnancy
Definition Gestational Diabetes Ectopic Pregnancy
- The state of carrying a fetus - Affects 9% of pregnancies - A fertilized egg implants outside the uterus
Demographics - Usually identified in month 5 or 6 - Usually in uterine tubes
- 60 million women are in their childbearing years in US - Risks to mother and baby:  Can be in peritoneum, on ovaries, etc.
- About 6 million known pregnancies/year  Macrosomia (dangerously big baby); risk of respiratory - Can’t come to term
- About 4 million births/year distress syndrome; early hypoglycemia, later obesity; - Associated with history of…
- 2 million births are interrupted by miscarriage, elective type 2 diabetes for both mother and child; repeated  Pelvic inflammatory disease
termination, stillbirth, other complications incidence of gestational diabetes with each child  Endometriosis
Etiology Pregnancy-Induced Hypertension  Sexually transmitted infection
- Physiologic changes during pregnancy are many and complex - 3 categories:  Adhesions from pelvic surgeries
- We will focus on common or dangerous complications that may  Hypertension alone Treatment
threaten the wellbeing of the mother or the baby  Pre-eclampsia - No treatment for uncomplicated pregnancy
Signs and Symptoms that Pertain to Massage Therapy o Hypertension + elevated proteins in urine, - Treatments as necessary for complicated pregnancy
- Loose ligaments systemic edema Massage Therapy Implications
 Can lead to low back pain, subluxation, muscle spasm o Affects 6-8% of all pregnancies Risks:
- Fatigue  Eclampsia 1. Trimester
 From extra weight, dedicated metabolism, hormonal o Pre-eclampsia + convulsions, risk of coma From the time she knows she is pregnant through delivery,
commands to rest - Most cases seen in… intrusive abdominal work should be avoided
- Shifting proprioception  1st pregnancies or teen pregnancies 2. Trimester
 Clumsiness, easy injuries  Women over 40 Be careful with positioning; at some point being prone will
- Depression  Women who are obese before pregnancy no longer be comfortable. Use bolsters, pillows, or a
 Anxiety and depression in response to concerns about  History of hypertension pregnancy table if possible
new phase  Carrying multiple babies 3. Trimester
 Can interfere with quality of life, ability to bond with  Underlying condition (lupus, scleroderma, diabetes) She may not be able to be prone or supine (the fetus can
new baby - Complications obstruct blood flow in the pelvis)
Types of Pregnancy Complications  HELLP syndrome: Hemolysis (destruction of blood Risk of blood clots, thromboembolism rises
Asthma cells), Elevated Liver enzymes, Low Platelets Watch for signs of pre-eclampsia: dizziness, edema,
- Incomplete control of asthma is linked too…  Renal failure headache, faintness, nausea: this is a medical emergency
 Low birth weight; prematurity; cerebral palsy; mental  Hemorrhagic stroke Benefits: As long as pregnancy is uncomplicated, massage therapy
disability; pre-eclampsia  Liver damage may be a great part of going through this process
- Well controlled asthma is linked too  Retinal detachment, blindness Options: Some experts suggest that a woman in advanced
 No particular risks pregnancy should only lie on her left side. Special training to work
 Several others…
Thromboembolism with this population is available and highly recommended
- Deep vein thrombosis + pulmonary embolism Research: Some research supports massage therapy for pregnant
- Pregnant and postpartum women have 10 x risk for blood clots women for a variety of goals. The effectiveness of massage therapy
- Risk increases with pregnancy development, stay high for during labor and delivery is well-accepted.
several days after delivery
Pregnancy is the state of carrying a fetus The signs and symptoms of advanced pregnancy are obvious, but Risks: The risks of bodywork for a pregnant client vary by trimester,
symptoms that specifically pertain to massage include loose and they may also be connected to any complications the woman
ligaments, muscle spasms, clumsiness, and fatigue experiences.
Benefits: Bodywork can be adapted for every trimester to help the
mother with some of pregnancy’s most common problems,
including fatigue, muscle and joint pain, and clumsiness.
- Clinical 70 – pg 177
triOS Handout
- “a state of wellness associated with many interrelated changes that occur throughout the women’s body as the fetus develops”
- Both physiological and musculoskeletal changes occur during pregnancy and they affect virtually every organ in the body
- The min stages of pregnancy are the first, second and third trimester and occur over 40-42 weeks
- The fourth trimester is the post partum stage and may last 6-12 months after the birth of the child
- It is important for the therapist to be aware of normal and potentially abnormal changes
 Preventative treatment
 Refer to main health provider
 Maintenance of clients wellness
- Symptoms
 1st trimester
 Nausea/vomiting
 Morning sickness
 Usually in the early stages, decreases at 10 weeks gone by 14 weeks
 Morning is most severe, but can last all day
 Medication may be prescribed in severe cases
 Frequent urination
 Up to every 2 hours
 Due to progesterone 9relaxes smooth muscle of the bladder)
 Decreases by 2nd trimester
 Will return in the later stages of pregnancy due to pressure of the uterus
 Constipation
 Very common
 Due to progesterone decreasing transit time
 Also due to mechanical pressure
 Blood pressure
 Will decrease in early stage—especially diastolic
 This is due to progesterone relaxing the muscles of vessel walls causing VD
 The placenta is acting as an arteriovenous shunt decreasing peripheral sistance
 Light headed, faint—especially within prolonged standing
 Extreme fatigue/lack of energy returns to normal around 14 weeks
 Breast Changes
 Increased fullness, tenderness, sensitivity
 Commonly located at the front of axilla
 Musculoskeletal changes
 Influences by progesterone, estrogen and relaxin
 Estrogen preps the site for action of relaxin
 Relaxin: can begin to release at 2 weeks, typically the highest in the 1 st trimester between 10-13 weeks, then decreases by 20%
 Affects the composition of collagen in joint capsules, ligaments, fascia—allowing for more elasticity
 Joints most affected are the symphysis pubis, SI joints, and joints that bear weight—feet, pes planus formation
 Taste and Smell
 Altered in early stages
 May last all pregnancy
 Reactive to foods, and smells in both negative and positive ways
 Mood Swings
 Common in 1st trimester but can last throughout
 Extreme fatigue increases irritability/depression
 2nd trimester (months 4-6 to 13-26 weeks
 Known as the “quiet months”
 Risk of miscarriage has decreased but could still occur
 Reality of fetus
 Hearing heart beat
 View through ultrasound (sonogram)
 “quickening” feeling of movements
 Test results at 18-20 weeks may indicate any possible problems
 At 23 weeks the fetus can survive a premature birth
 Edema
 Common at any stage
 Up to 40% of women experience it in the legs
 Due to fluid retention/mechanical obstruction by uterus
 Increased venous pressure distally
 Can also be due to excessive weight gain
 Can be a symptom of Pre-Eclampsia need to be referred back to midwife or physician
 Hypertension
 Can be chronic—existed before
 Can be pregnancy induced hypertension (PIH)
 Serious concern in pregnancy
 2nd most common cause of maternal death
 Also contributes to fetal/neonatal morbidity/mortality (cerebral palsy/other mental and physical disabilities
 The baby is at risk when blood flow to the placenta is decreased by ½
 Pre-eclampsia = sudden increase in BP (degree of elevation is more significant than value)
 Diagnosed when increase BP and increased concentration of protein is urine (proteinuria) and general edema
 Edema: face and hands is a better indicator or pre-eclampsia than if in the lowers
 85% develop edema
 15% develop pre-eclampsia
 Eclampsia = all symptoms + convulsions
 Causes of pre-eclampsia is unknown
 Women who are predisposed are:
 1st pregnancy
 Multiple pregnancy
 Pre-existing chronic hypertension
 Hydatidiform mole: a degeneration process affecting the villi that connect to the part of the endometrium which gives rise ot the placenta (causes multiple cysts and hemorrhaging
 Chronic renal disease
 Diabetes
 Malnutrition
 History of PIH in the family of previous pregnancy
 Younger than 20 or older than 30
 Developing hydramnios—excessive amniotic fluid
 Taking accurate BP requires more care as different positions can alter the readings
 Highest reading when standing or sitting
 Lower when supine
 Lowest reading when side lying
 Supine hypotension
 As early as 4 months and will continue
 Compress aorta and inferior vena cava against L/S
 Feel faint when supine
 Shortness of Breath
 Any time in pregnancy
 Dyspnea: abdominal contents are pushed up from the increasing size of the uterus causing upward pressure on diaphragm
 The diaphragm is raised by approximately 4 cm and laterally expands up to 2cm
 The sub sternal angle also increases from approximately 70’ int the 1 st trimester to 105’ at term with thoracic circumference increasing 5-7cm
 Rib flaring can cause pain along the anterior costal margin and associated with T/S pain
 Shortness of breath with exertion or laying flat
 When baby’s head drops in the 3rd trimester breathing becomes easier
 Physiologically 20% more O2 is needed due to the increased basal metabolic rate
 Breathless as body adjusts to new demands
 Increased oxygen = increased carbon dioxide
 Medulla oblongata responds by increasing breathing rate especially with activity
 Backaches
 Common
 Stress on softened/stretched ligaments and tendons supporting the pelvis and L/S may cause surrounding muscles to spasm to support
 Posture changes as centre of gravity moves
 Hyperlordosis – abdominal changes
 Hyperkyphosis – breast changes
 Changes may begin as early as 4 months and may last months post partum
 88% have LB pain at some point in pregnancy
 Abdominal Pain
 Can be from the same thing that causes pain in abdominal pre-pregnancy
 The greatest concern is for previously unexperienced pain with sudden onset—medical advice
 Round Ligament – supports the uterus, runs along the side of uterus and passes from upper portion down to the groin
 Linea alba and Rectus Abdominal muscles
 Intense stretching
 May separate 2nd or 3rd trimester, stops by 33 weeks
 Diastasis Recti—sharp pain more intense on right than left side
 Diastasis Symphysis Pubic
 Pan varying in severity over pubic area and inner thigh
 Separation of symphysis pubis
 Varicose Veins
 Can develop any time, typically in later stages
 Veins in pelvis are compressed causing decreased venous return and increased pressure on the veins
 Weight gain contributes
 Mild = may decrease or resolve in 1st 6 months postpartum
 Severe = may only partially regress
 Often return with increasing severity with each pregnancy
 Hemorrhoids
 In and around the rectum
 Pigmentation changes
 Skin – freckles enlarge
 Birthmarks/moles may darken
 Chloasma – butterfly mask over nose and cheeks may develop in the latera half of gestation
 Linea nigra – dark line from top to bottom of abdomen, no medical concern and typically returns to normal
 Stretch marks
 In areas that are rapidly enlarge – breasts, abdomen
 Also in other areas of weight gain – legs, gluteus, upper arms
 Emotional
 Mixed feelings of body changes
 Therapist needs to be respectful and non-judgmental of women’s emotional state
 Other changes
 Nose bleeds
 Gum bleeding – risk of gingivitis increases in pregnancy client should check in with dentist more regularly
 Nasal congestion
 HA’s – frontal and above eyes
 Migraines may either increase or get better
 3rd trimester – months 7-9, weeks 27-42
 Many second trimester symptoms continue
 Physical discomforts increase has head drops
 Gestational Diabetes
 Develops during pregnancy
 No known risk factor
 Increased insulin in blood due to insulin resistance in body
 Diabetes mellitus may have adverse effects on pregnancy
 Increased risk for pre-eclampsia/eclampsia
 Possibly hydramnios causing difficult with breathing and risk of premature labor
 Macrosomnia – baby weights more than 10 lbs
 Predisposed to postpartum hemorrhage
 Ketoacidosis
 Another danger secondary to diabetes
 2nd and 3rd trimester not eating for longer periods due to stress
 Associated with maternal mortality rate of 5-15%
 Education about control is essential
 Treated with exercise, diet and possibly insulin
 Increased risk of developing diabetes later in life
 Edema
 Legs, hands, fingers, face – be aware and refer out if concern of pre-eclampsia
 Morning hands feel stiff
 Compression syndromes secondary to edema causing pins and needles
 Compression Syndrome
 TOS/CTA secondary to edema in arms/hands
 Sciatic nerve compression
 Piriformis syndrome, legs externally rotate to accommodate for pain
 TPs in buttock refer down the leg
 Back aches
 May increase
 Shift centre of gravity, the effects of progesterone and relaxin
 SI Sprain
 Intense pain over sacrum
 Often worse with rotation movements like turning sideways in bed
 Leg cramps
 Especially claves, often at night and can wake up client
 Increase in frequency in the last trimester
 Can be a sign of DVT refer out if there is a concern
 Pelvic Discomfort
 Often begins around 30-32 weeks
 Due to softening of ligaments and extra mobility of the joints
 Achy heavy feeling after 36 weeks with the head dropping
 Head can compress the nerves
 Symphysis Pubis – not usually a serious condition
 Pain with baby kicking
 Costal Margin Pain
 Uterus compresses lower ribs – 30-34 weeks
 Right more than left
 Relief when moving out of a sitting position
 Frequent Urination and Incontinence
 Increased pressure on the bladder
 Influence of hormones on the urethra and pelvis floor muscles
 Fatigue increases
 Insomnia and Restlessness
 Very common
 Difficulty finding a comfortable position
 Heart burn, fetal movement, frequent needs to urinate
 Emotional
 Most concerns have been resolved
 Delivery
th
 4 trimester – “post-partum”
 Physical changes
 Linger after birth – need time to regain body balance
 Ligaments are the longest and joints are most unstable immediately postpartum
 Severe back pain may persist
 Shoulder and back pain may be due to poor posture when breast feeding/lifting and holding baby
 Post Surgical Recovery – episiotomy / C-section / cesarian
 Episiotomy: incision in perineum before birth to help prevent tearing
► Exercise before can help prevent this
 Cesareans: major abdominal surgery
 with no complications 4-6 weeks recovery
 Breasts
 Sore with cracking around nipples from breast feeding
 Resolves with care and continued use
 Emotional
 - may be joy
 May be sadness, fear, anger, anxiety
 Postpartum blues: mild may last a few hours to a few weeks
 Postpartum depression
► Strong feeling of sadness anxiety or hopelessness
► Counselling or treatment are required
► Signs and symptoms
▷ Postpartum blues lasting more than 2 weeks with strong depression/anger a few months after birth
▷ Increasing anger, hopelessness, sadness that interferes with ADLs
▷ Inability to sleep even when tired or sleeping most of the time even when baby is awake
▷ Extreme appetite changes
▷ Excessive worry about the baby or little interest in baby and family
▷ Panic attacks
▷ Fear of harming baby or herself
► Therapist should strongly recommend consulting a physician for treatment
- Healthy History
 General health
 History of cardiac, renal, thyroid, pulmonary, GI, or hepatic disease
 Stage of pregnancy, multiple
 Previous pregnancy – number of births
 Complications
 Family history of complications
 Current symptoms/complications
 Current BP – check throughout if concerned
 Use an additional HH questionnaire for pregnancy
- Massage
 Primary massage treatment goals
 Promote healthy pregnancy
 Relaxation
 Supportive environment
 Hydrotherapy for any trimester
 warm foot bath – lemon essential oil for achy varicosities
 heat decreases pain, increases local circulation to HT muscle and increases relaxation—back, glutes and neck
 contrast or cold/wraps—feet legs to decrease edema
 cold figure 8 wraps—breast to decrease congestion and pain
 essential oils after 4th month—lavender, neroli, tangerine
 essential oils for labour—geranium, lavender marjoram, arnica
 1st Trimester
 Prone, supine, side-lying
 GSM with focus areas
 Some women may be uncomfortable in prone at end of trimester
 Gentle stroking and petrissage in abdominal, LB and sacral areas
 2nd & 3rd Trimester
 Address individual symptoms
 Goals: decrease pain and postural discomforts, maintain wellness
 Focus on decreasing TP, muscle spasm, HT—low back, glutes and neck
 Treat Hyperlordosis other postural dysfunctions, and compression syndromes
 Decrease edema
 Position = side-lying, supine and seated
 Supine hypotension may occur but can be relieved by placing a folded towel under right hip (reposition weight of fetus off vascular structures), side-lying on left will do the same
 Semi-seated while supine from end of 2 nd to delivery—10 to 15 minutes
 Its important for client to inform therapist of nausea and discomfort—change position or stop treatment
 When treating hyperlordosis avoid releasing supportive fascia
 Side lying—treat back; focus on LB, QLs, ES
 FTK iliac crest—abdominal obliques
 Stripping/spreading to intercostals, serratus anterior
 Scooping latissimus and along ribs
 Upper back and chest (kyphosis) fascial tech, muscle stripping but caution of tender breasts
 Lateral neck muscles
 Rotator cuff muscles and muscles of scapula
 With hyperkyphosis do not stretch rhomboids and middle traps
 Glutes focus on piriformis, muscle strip, and fascial work
 Lymph drainage for legs
 Treat pes planus
 Decrease pressure with varicosities
 Supine treat HNS
 Stretch to neck
 Soothing face massage/scalp
 Compression syndromes treat with modification
 Decrease pressure from edema
 Breast tenderness
 Cold hydrotherapy decreases congestion
 Lymphatic drainage, breast massage—be careful with tenderness
 Abdominal massage
 Constipation
 Facilitate relaxation
 Clockwise
 Broad hand contact
 Gentle specific stripping/pressure points at costal border and iliac crest
 Passive joint ROM throughout body to maintain joint health
 Avoid aggressive joint play
- Labour
 “doula” give support during labour
 Knowledge of process and ability to stay calm and focus in order to listen to clients needs
 Position is up to women and may change frequently
 Some women prefer not to be touched during labour
 Treatment to decrease pain, anxiety
 Supportive touch helpful to calm
 Therapist can guide partner
 Early stages massage over sacrum—essential oils Fiona
 During active labour massage is directed by women—abdominal, LB, legs, forehead
 Back labour caused by occipitoposterior position of baby
 Often relieved with massage gentle mobilization techniques to hypomobile SP
 Pressure points along the spine
 Transitional stage of labour
 Pain intensifies
 Reassurance and support
 Birth: compresses to face/stroking between contractions
- Immediately Postpartum
 Massage every 4 hours can assist in involution of the uterus (decrease size after delivery)
 Relaxation massage is appropriate in weeks after birth to decrease stress, aid in milk production (breast massage)
- Long-Term Treatment Goals Postpartum
 Focus on regaining posture and biomechanics
 Difficult deliveries (back labour) may contribute to long lasting back pain
 Exact mechanism is unclear
 Possible lumbo-sacral sprain or SI sprain
 Can injure pelvic joint or L/S
 Assess these areas prior to treatment
 Cesarean surgery—once healed address hyperlordosis and scar tissue
 Joint laxity can last up to 6 months or longer
- Self-Care During Pregnancy
 Relaxation exercises
 Deep diaphragmatic breathing
 Relaxation CDs
 Visualization—increase relaxation and help with insomnia
 Self-massage to costal borders and suprapubic attachments and perineum
 Perineum massage given by midwife, partner or physician
 Leg cramps: circulation exercises, foot massage, prior to bed
 AROM of ankles, toes and knees
 Once cramp occurred active inhibition stretching
 Massage is encouraged
 Will relieve cramp in a few minutes
 Tenderness may remain for several hours/days
 Varicose veins: avoid excessive weight gain
 Avoid crossed leg/prolonged sitting
 Avoid tight clothes at waist and legs
 If developed use support hose
 Elevate feet/legs when sitting
 Gentle passive ROM to ankles and knees
 Mild to moderate exercise program is encouraged throughout—continue activity prior to pregnancy
 Posture imbalances changes to carrying baby
 Progressive weight training
 Stretched scalenes, scapular protractors, shoulder internal rotators, levator scapula, hip adductors, knee flexors, gastrocnemius
 Strengthen upper neck flexors, shoulder extensors, external rotators, scapular retractors and depressors, hip extensors, ankle dorsiflexors
 Start early in pregnancy
 Diastasis symphysis pubis/diastasis recti—refer to physio for specific exercises
 Caution with certain movements
 Never do leg raises or sits up from supine
 Frequent Urination/incontinence
 Strengthen pelvic floor muscles
 Resist the passage of urine—small bursts 3-5 seconds long
 Do action in supine seated and standing
- Self-Care after Delivery
 Specific rem-ex for restoration for postural alignment
 Hydrotherapy
 Hot for sore muscles
 Cold for inflammation
 Relaxation strategies
Pre-menstrual Syndrome
Premenstrual Syndrome
- Collection of signs and symptoms that interfere with a - Described since ancient times - Low-dose birth control
woman’s ability to function normally during the luteal phase of - Recognized as a disorder in 1953 - Diuretics
the menstrual cycle - Several contributing factors, theories - Antidepressants
 Between ovulation and menstruation  Hormonal hypersensitivity + exposure to exogenous - Get good sleep, exercise
Demographics estrogen - Low-fat, vegetarian diet
- Up to 75% of women in US report some sign of PMS o May cause endometrium to become - Avoid salt, sugar, caffeine, alcohol
- 3-8% report signs of premenstrual dysphoric disorder (PMDD) overactive, exacerbating fluctuations - Borage
- Women who are obese, women who smoke are most at risk  Nutritional deficiencies - Evening primrose
Signs and Symptoms o Calcium, magnesium, folic acid, B6, some - Saffron
- Identified when symptoms are present in 10 days leading up to essential fatty acids - Black cohosh
menstruation, subside when menstruation begins  Neurotransmitter imbalance - Chasteberry
- 150 + signs and symptoms documented, loosely characterized o Changing estrogen/progesterone may suppress Medications
as… secretion of serotonin, opioid peptides - Hormone supplements to suppress ovulation
 Physical manifestations  Other factors - Diuretics
o Bloating, breast tenderness, acne, cravings, o Genetic predisposition - Herbal remedies
headaches, backache, insomnia, many others o Cultural expectations Massage Therapy Implications
 Emotional manifestations o General stress Risks: Massage therapy has no risks for a person with PMS
o Confusion, poor concentration, mood swings, o Unrelated disorders Benefits: Massage therapy may help with some of the physical and
depression, anxiety, panic attacks, irritability psychological aspects of this disorder
Research: Many women with PMS receive massage therapy, but at
this point the research does not support its use as an effective
modality for PMS
Premenstrual syndrome (PMS) is a collection of many signs and Signs and symptoms of PMS are often divided into physical and Risks: Massage has no specific risks for women with PMS
symptoms that occur in the time between ovulation and emotional features. Physical symptoms include breast tenderness, Benefits: Massage and bodywork may offer wonderful support for
menstruation, and then subside after menstruation begins. It may bloating, digestive upset, fatigue, changes in appetite, backache, a woman whose negative physical experience is predictable,
have several causes and triggers. and many others. Emotional signs include irritability, anxiety, potentially debilitating, and tremendously frustrating.
depression, mood swings, and other possible problems.
Sexually Transmitted Infections
Sexually Transmitted Infections

Definition Chlamydia Bacterial Vaginosis
- Contagious diseases spread through intimate contact - Bacterial infection with Chlamydia trachomatis - Exclusive to women
 Main modes of transmission:  Can develop in mouth, throat, reproductive tract, anus - Imbalance in bacterial environment of vagina
o Vaginal, oral, anal sex - Often silent  Foul-smelling discharge
 Some may be passed from mother to baby via blood or  ¾ of women, ½ of men report no symptoms  Irritation
in the birth canal - Symptoms include:  Increased risk of: catching, spreading other STIs; pelvic
Demographics  discharge; pain, burning during urination; painful inflammatory disease (PID); complicated pregnancy
- Chlamydia: 3 million new infections/year intercourse - Treated with antibiotics
- Gonorrhea: 820,000 new diagnoses/year - Complications: Nongonococcal Urethritis
- Syphilis: 55,000 new infections/year (Doubled since 2000)  PID (pelvic inflammatory disease); risk of infertility, - Bacterial infection or urinary tract
- Trichomoniasis: 4 million probably have it; 30% will have ectopic pregnancy; epididymitus, infertility; baby may  NOT gonorrhea
symptoms be exposed in birth canal (conjunctivitis; pneumonia)  Usually STI
- Genital warts: - Treatable with antibiotics  Can be related to other problems
 79 million have HPV  All sexual partners must be treated too  Treated with antibiotics
 14 million new infections/year  Exposure does NOT impart immunity Trichomoniasis
 360,000 new cases of highly contagious warts  Co-infection with gonorrhea requires 2 different - Protozoan infection
Etiology antibiotics  Discharge, pain, itching
- Most infections are spread through sexual activity with an Syphilis  Increased risk of HIV transmission
infected partner - Bacterial infection with Treponema pallidum  Birth risks in pregnant women
- Some can be shared mother-fetus  Sexual contact and mother-child - Treated with antibiotics; reinfection is common
- Transmission can be prevented  Travels through blood to joints, blood vessels, CNS Molluscum Contagiosum Virus
 Abstinence  Fragile outside a host - Often benign, not STI in children
 Relations only with uninfected partner - Moves in stages - In adults can appear on thighs, groin, buttocks, external
 Barrier methods provide good protection but…  Primary syphilis: 10 days-3 months after exposure, genitalia, anus
o More skin touches than is covered by male and characteristic chancre sore – very contagious, heals in Genital Warts
female condoms 3-6 weeks - AKA: condylomata acuminate
Types of Sexually Transmitted Infections  Secondary syphilis: rash of open sores on feet, palms - In women: on vulva, walls of vagina, perineum, cervix
Gonorrhea (could be anywhere); highly contagious, comes and - In men: on penis, scrotum, anus
- Bacterial infection with Neisseria gonorrhea goes for 1-2 years - In both: in mouth, throat
 Affects mucous membranes in throat, vagina, rectum  Tertiary syphilis: 1/3 of people have invasion of other - Highly contagious
- Rarely transmitted except by sexual activity systems, including the brain - Usually small, can become large
- May spread beyond mucous membranes - Increases risk of HIV transmission - Some associated with types of cancer
 Gonococcal arthritis can cause permanent damage - Pregnant woman may miscarry, or pass the infection to the - Can be removed with topical medication
- Often silence child - HPV vaccine protects from several forms of genital warts
 Women: discharge, urinary discomfort, painful  Can cause CNS problems in baby Medications
intercourse, mouth lesions - Treated with 1 dose of penicillin - Antibiotics for bacterial and protozoan infections
 Men: discharge, painful urination, orchitis (swollen  Must happen in Stage 1 or 2; organs damage is - Antiviral medication for viral infections
testicles) permanent - Topical applications for genital warts, molluscum contagiosum
- Treated with antibiotics Massage Therapy Implications
 Developing resistance Risks: Communicability is not an issue in a massage therapy setting
 Needs different antibiotics than chlamydia except for when lesions are open and accessible. Be aware that not
all lesions associated with STIs are confined to the genitalia.
Benefits: Clients who are under treatment or who have completed
treatment for STIs can enjoy all the benefits from massage therapy
as the rest of the population.
Sexually transmitted infections (STIs) are contagious conditions The major STIs all share some signs when any signs are present at Risks: Massage is unlikely to have a directly negative impact on an
that are spread through intimate contact. Pathogens can be all. These include penile or vaginal discharge, painful urination, and STI, but undiagnosed conditions can continue to spread and
bacteria, viruses, or protozoa. painful intercourse. Other more specific symptoms vary by damage more tissue until they are treated. People with very
causative agent. advanced infections may have cautions for massage related to
having other tissues affected.
Benefits: Once an infection has been identified and controlled,
massage within a client’s capacity for adaptation is appropriate.
People who have full recovered from STIs can enjoy the same
benefits from bodywork as the rest of the population.
Principles of Cancer
General: Cancer
Principles of Cancer Viruses Associated with Cancer Risk Cancer Treatment
- 100+ different diseases - Human T-Cell lymphotrophic virus-1 (HTLV-1), similar to HIV - Surgery
 Normal cells mutate, replicate uncontrollably  Lymphocytic leukemia, Hodgkin lymphoma  Remove malignancies with clean margin
- Epithelium = carcinoma - Human papilloma virus  Remove sample or sentinel lymph nodes
- From muscle or connective tissue = sarcoma  Cancer of the cervix, penis, anus, vagina, vulva, mouth, - Chemotherapy
- From blood or lymph = hematologic cancer throat  Cytotoxic drug target fast-growing cells
“Skilled massage therapy is safe for people with cancer and will not - Human herpesvirus 8 - Radiation therapy
spread the disease. Specific massage adjustments are based on  Kaposi sarcoma  High-energy rays to kill cancerous tissue
clinical presentations of cancer, not the presence of a cancer - Human immunodeficiency virus  From a machine or implanted pellets that are later
diagnosis” –Tracy Walton  Cancers from viruses that would otherwise be resisted removed
Cancer Statistics (HPV, HH8) - Radiofrequency thermal ablation
- #2 cause of death in the US - Hepatitis B and C viruses  Instruments pass an electric current through cancerous
 A man’s lifetime chance = 1:2; A woman’s lifetime  Liver cancer tissue without removing it
chance = 1:3 Bacteria Associated with Cancer Risk - Stem cell implants
 Usually in people over 55 - Helicobacter pylori  For leukemia, to replace cancerous bone marrow
- 1.7 million cases diagnosed/year  Converts nitrites to carcinogens; stomach cancer, - Hormone therapy
 Doesn’t include non-melanoma skin cancer, anything lymphoma  Limits how cancer cells access hormones
found in situ - Others - Hypothermia
- Survival rate is improving  Borrelia burgdorferi, Campylobacter jejuni: seen with  Freezing off cells
 Better screening digestive tract lymphoma - Hyperthermia
 Better treatment options Animal Parasites Associated with Cancer Risk  Heating up medications or core temperature to make
- 13.7 million in US have a history of cancer - Live flukes medications work better
 Most common diagnosis = non-melanoma skin cancer  Cancer of bile duct - Biologic (targeted) therapies
 Most common cause of death = lung cancer (men + - Schistosoma haematobium  Using “trained” immune system cells
women)  Worms that cause bladder cancer - Photodynamic therapy
 Then… Signs and Symptoms  A drug + light to activate it
 Breast, ovarian for women - Common red flags: Massage Risks for Cancer
 Prostate for men  A change in bowel or bladder habits, blood in stool or - Tumor sites
 Colon, rectum for both urine  Don’t work on or near tumors or undiagnosed lesions
Steps in Metastasis  A sore that doesn’t heal; comes and goes in same place - Bone fragility
- Oncogene activation  Skin changes: color, itching, hair growth  Some cancer metastasize to bones easily, especially
- Local invasion  White patches in the mouth ribs and vertebrae
- Proliferation  Bleeding, spotting between periods or after menopause - Vital organ involvement
- Angiogenesis  Thickening or lump in breast or elsewhere  Lungs, liver, brain, kidneys, heart
- Migration  Enlarged prostate - Deep Vein Thrombosis
- Colonization  Indigestion, trouble swallowing  A risk during cancer and for several months after
Cancer Prevention  Persistent cough, hemoptysis treatment is concluded
- Don’t use tobacco - Use sunscreen, protective  Unexplained weight loss - Surgery
- Achieve, maintain healthy clothing  Fatigue, anemia  Infection, constipation, medical device
weight - Practice safe sex  Unexplained fever - Lymphedema
- Be physically active - Vaccinate against cancer-  Unexplained, unremitting pain  From cancer or cancer treatment; responds well to
- Consume a healthy diet causing pathogens Cancer Screening specialized treatment but not to standard massage
- Limit alcohol consumption - Know your family history; use - 2 goals: - Radiation therapy
- Avoid known carcinogens early screening as necessary  Find cells while treatment is most likely to be successful  Damaged skin, implanted pellets, many side effects
Causes of Cancer: Internal Factors  Lead to an increased overall survival rate that inform massage therapy choices
- Inhibited apoptosis - Recommendations in sidebar: 12.1 - Chemotherapy
- Inherited gene - If suspicious changes are found…  Important side effects, including hand-foot syndrome,
 Could be for a cancer type (breast, colorectal)  Biopsy neuropathy
 Could be for a reaction to an environmental trigger  Further examination and staging if necessary Massage Therapy Benefits for Cancer Patients
- Hormonal activity Cancer Staging - Improved sleep
- Immune system problems - Identify progression to choose the best treatment options - Increased appetite
Causes of Cancer: External Factors - TNM system: - Constipation relief
- Environmental carcinogens  Tumor (size, number) - Improved mood
- Viruses  Node (number, location) - Reduced anxiety
- Bacteria  Metastasis - Decreased depression
- Animal parasites - 0 to IV system: - Alleviated pain
Environmental Carcinogens  0: in situ Research on Massage Therapy and Cancer
- 240 known carcinogens  IV: distant metastasis - Most studies and reviews conclude that massage therapy has
 Hydrocarbons in cigarette smoke - Grade: many potential benefits for cancer patients, but the state of
 Compounds from grilling meat  Differentiation of cells the research is still lacking
 Chemicals from ink, dye, pain  Aggressiveness of cells
 Radiation Cancer Treatment
 Asbestos - Neoadjuvant treatment: before main treatment begins
 Benzene - Adjuvant: after main treatment is completed
 Nickel - Palliative: treat symptoms for quality of life
 Cadmium
 Etc…
- Cancer is a general term used for the abnormal, uncontrolled growth of cells
- Tumor or neoplasm are used to describe new growths
- Neoplasm fuel their growth by using nutrients and blood supply of their hosts
- They have a silent period  may be months, years or decades before they are noticeable or cause enough pressure to result in symptoms such as pain or bleeding
- Benign tumor are encapsulated growth compromised of slowly proliferating cells
 Are not serious unless they compress vital structures
- Malignant tumor can destroy other tissues
 Have 2 qualities:
 They are invasive
 Able to move to new sites  blood of lymphatic system
 Aka metastasizing
- Most are destroyed by the body’s immune system
- Naming Types of Cancer
 Oma is use to designate a tumor
 Carcinoma originates in epithelial tissue
 Sarcoma originate from connective tissue
 Highly malignant, but not common
- Cancer Rates
 Breast cancer for women and prostate cancer for men
 Declining rates of mortality
 Lung, colorectal and prostate for men
 Women is lung, colorectal and breast cancer
 Leading cause for both is lung cancer
 Women is increasing mortality rate, 4 times
- Causes of Cancer
 200 different disease
 Genes in healthy cells can be transformed into genes that promote cancer growth oncogenes
 Cancer development is cumulative process
 Can strike any age, but more common in older people
 70% of new cases, 80% of death, are those 60+
 Genes effect cancer in 2 different way:
 Carcinogens
 Chemical and environmental agents
 Cigarette smoke
 Radiation from UV rays or sunlight
 Drugs and hormones (immunosuppressors and estrogen
 Industrial agents or toxic substances (asbestos, chromium, coal tar, benzene, cadmium, radon, uranium and nickel)
 Excesses or deficiencies in diet (low fiber and high fat)
 Heredity
- Contributing Factors
 Weakness of the immune system secondary to excessive or chronic stress, disease or immunosuppressor drugs
 Alcohol in 4% (head, neck and liver)
- Medical Treatment
 Surgery
 Side effects:
 Anesthesia use, respiratory complications, bleeding, DVT, infections from incision, pain and fatigue
 Restrictions from scarring, bowel obstruction or blockage
 Chemotherapy
 Side effects:
 Nausea and vomiting most common
 Medication for it causes drowsiness and fatigue
 Hair loss, mouth sores, nausea, diarrhea or constipation and low blood count
 Low blood count causes malaise, fatigue, anemia, increased susceptibility to infections, bruising and bleeding
 Some drugs result in peripheral neuropathy like burning in hands and feet
 Radiation Therapy
 General side effects:
 Fatigue
 Skin reactions (temporary) similar to sunburn [redness, tenderness, slight swelling and peeling]
 Permanent skin changes like thickening and deep tanning
 Localized side effects:
 Head, face and neck causes dry mouth, alters taste, hair loss
 Chest can irritate the esophagus (heart-burn), difficulties chewing or swallowing and coughing
 Immunosuppressants can lead to pneumonitis lung inflammation 3 month post-treatment caused by bone marrow damage include dyspnea, cough and low grade fever and edema
 Aggressive treatment and drugs can cause cardiopulmonary dysfunction (Hodgkin’s disease) and breast and lung cancers resulting in exercise dyspnea, pericardial fibrosis and constriction pericarditis
 Fibrosis scarring occurs 9 months to 2 years post-treatment resulting reduced pulmonary function
 Breast radiation causes tenderness of breast and axilla
 Local edema for 4-6 weeks post-treatment
 Long-term changes in breast size
 Abdominal radiation can cause nausea or diarrhea
 Biological Therapy
 Destroys cancer cells by exploiting the immune system with purified proteins
 Used in treating melanoma, kidney cancer and some blood cancers
 Breast, ovarian and colon cancers
- Massage and Cancer
 Anxiety and stress, especially pain
 Psychological wellness
 Massage can reduce symptoms of pain or muscular tension, relaxation, stress reduction, support the immune system
 NOT supported that massage therapy metastasizes cancer
 Circulation depends on the type of cancer
- Warning Signs of Cancer
 Personal or familial history of cancer
 Namely breast, colon and lung
 Bowel, urination
 Healing time of injuries (6 weeks)
 Bleeding (prolonged menstruation) or prolonged discharge
 Thickening or lump
 Changes in digestion, indigestion or constipation
 Difficulty swallowing or eating
 Chronic coughing, recurrent laryngitis, hoarseness or difficulty speaking
 Changes in size, shape or color
 Sudden loss of weight (10-15 lbs)
 Headaches or change of vision
 Proximal muscle weakness with decrease DTR
- Warning Signs of Advanced Stages of Cancer
 Chronic pain, bone pain
 Unexplained bleeding
 Ulcerations, around tumor or tissue, growth of tumor, pressure
 Tissue health, necrosis
 Secondary infection
 Severe hemorrhage
 Persistent fatigue
- Contraindications
 Post-surgical massage is locally contraindicated
 Hands and feet for relaxation
 NOT neck, head or back (depends)
 DVT
 Radiation frequently creates local burns and loss of epithelial cells
 Creams, powder, ointment, lotion, oils and salve should not be used over affect tissue
 Avoid use for several weeks
 Sensitive to touch, thus contraindicated
 Hydrotherapy contraindicated
 Chemotherapy
 Depends on nausea and the tolerance of client
 Lymphatic drainage techniques are contraindicated with untreated or metastasizing neoplasms including melanomas
 From medical treatment from physician consult
 Hot hydrotherapy application are contraindicated with lymphedema
 Possibly for years
 Heavy pressure techniques or friction, should be avoided at the scar or distal limb to not provoke lymphedema
 Fully body massage avoid areas of cancer
 Vigorous or stimulating techniques or treatments of long duration are contraindicated for debilitated clients, especially those receiving palliative care
- Assessments
 Observation and Palpation
 Tissue health
 Redness and warmth after radiation
 Tissue wasting and atrophy if bedridden or terminal stages of cancer
 Edema due to lymphatic obstruction or removal of limb
 Congested and puffy
 Ascites found in abdomen
 Scar
 Fascial restrictions
 Reduced range of motion
 Postural dysfunction (frozen shoulder after mastectomy)
 Tenderness and pain
 Pain can increase with progression if terminal
- Massage During Medical Treatment
 Permission from physician
 Full-body massage may not be tolerated because of tumor site, surgical site or radiation
 Slow-stroking down the spine, hands or feet post-surgery or after chemo or radiation
 Stress-reducing
 Comfort and support
 Pain relief
 Symptom relief
 Visualization therapy
- Massage After Medical Treatment
 Stress-reduction
 Quality of life
 Treatment of edema, scar tissue and fascial restrictions
 Emotional support
 Painful restrictions or postural dysfunction
 Edema
 Breast and lymph
 Lymphatic drainage
 Regain joint movement
 Reduce postural imbalances
 Stretching
 PROM proximal and distal
- Palliative Care
 Best emotion and physical quality of life
 Do not push C to talk
 Relaxation massage
 Visualization
 Pain control
 Deteriorating and fragile tissue
 Gentle and soothing techniques
 Local massage on face, neck and hands
 Family and friends may also benefit
- Self-care
 Nutritionist
 Relaxation strategies
 Diaphragmatic breathing and meditation
 Exercise: regular walks, stretching and strengthening, (lymphedema) AROM
 Breast cancer should prevent shoulder dysfunction
 Pendulum and AROM
 Lymphedema C should seek training
 Quit smoking and eat healthier
- Common Types of Cancer
 Breast Cancer
 Who is Affected?
 Increases with age
 80% over 50
 Causes and Contributing Factors
 Increased risk:
 Familial or personal history before menopause
 Hormonal history
 Exposure to estrogen or early onset menstruation
 1st pregnancy
 Few or no pregnancies
 Limited breast-feeding period
 Late menopause
 Familial history of cervical, uterine or colon cancer
 Age, 40 1 in 262; 50 1 in 58
 High fat-diet
 Inactivity
 Symptom Picture
 Breast lumps
 Feel hard or irregular shaped
 Thickening of breast tissue
 Feeling differently to surround breast tissue
 Fibrocystic breast (small lumps) does not mean cancer
 Enlarged lymph nodes in axilla
 Pain more common in benign lump
 Changes in nipple or breast appearance
 Nipple retraction
 Nipple scaling  Paget’s disease
 Discharge from nipple: blood or serous
 Breast may appear irregular or retracted (size or shape, swelling, orange “peau d’orange”/edema, redness or heat)
 Bone pain
 Swelling in neck or liver
 Medical
 Surgery (lumpectomy [bit] or mastectomy [lymph nodes or entire structure])
 Radiation (armpit, breast and chest walls)
 Chemotherapy in combination
 Hormonal therapy to level out estrogen
 Removal of ovaries or drugs
 Post-treatment Complications
 Obstruction of lymphatics
 Leads to edema/lymphedema
 Cooling, warming or ischemia
 Bruise, cut, sprained ankle, pinprick of diabetes blood sugar or even an insect bite with lymphedema
 Massage
 Start on contralateral quadrant (right means left in the case of lymphedema)
 Colorectal Cancer
 Men and women equal
 Occurs before 50, unless predisposing factors like chronic ulcerative colitis, colorectal cancer, history or familial polyposis coli [multiple tumors]
 5 year survival rate in 70%
 Likely cancer is cured
 Metastasized to lymph node 30%
 Good prognosis in rectal, distal colon not so much
 5 year 60%
 Unknown cause
 Diet – too much fat, saturated fats
 Preventative factors include fiber, fruits and vegetable, vitamin C and E
 Symptom Picture
 Changes in bowel habits over 2 weeks – constipation or/both diarrhea
 Polyps (precursors) take years to change – in stool results in bleeding from intestine
 Poop is brigh or dark red
 Anemia – paleness, SOB and fatigue
 Crampy abdominal pain and swelling
 Rectal tumor
 Medical
 Surgery – large sections can be removed with little change to function
 Possible sphincter removal and anal canal
 Colostomy – abdominal section so stool can be removed
 Radiation (more likely) or chemo (combination)
 Massage
 Relaxation and support
 Colostomy, abdominal massage not recommended
 Positional modification with ¾ prone
 Lung Cancer
 Leading cause of death in both men and women
 Smokers (20+ years), increased risk 15-20 times compared to non-smoker
 Carcinogens (asbestos, chromium, benzene, cadmium, nickel, radon and coal tar) in 85%
 Most related to smoking
 Symptom Picture
 Chronic coughing
 Possible bloody phlegm
 Obstruction
 Secondary infection and pneumonia
 Chest pain
 Fever
 Medical
 Surgery, 30-35% doing well after 5 years
 Radiation if tumor can’t be removed
 Chemotherapy if metastasized
 Massage
 Stress reduction
 Post-treatment is postural changes
 Fascial restrictions
 Terminal: stress reduction and support
 Prostate Cancer
 1 of 9 men
 Men over 70, rare under 50
 Slow growing
 If prostate remains normal life
 Unknown
 Diet – fats, particular animal fats
 Symptom Picture
 Asymptomatic, only detected after it metastasizes to another area
 Emptying bladder causes infection, pain or burning with urination
 Difficulty urinating or weak steam
 Infrequent urination or leakage
 blockage
 Medical
 70+ will just watch if slow growing
 Surgery to remove prostate
 Radiation destroys cells
 Hormone replacement or stopped if metastasized or advanced
 Possible removal of testes
 Impotence results
 Massage
 Stress reduction and support
Other Conditions
Infant Massage  Handout
- Infant reflexes
 Moro/Startle Reflex
 Sudden change of position, dropping head backwards, loud noises
 Response = baby throwing out arms and legs as if they are falling (stress cue/response)
 Up to 4 months gone by 6 months
 Evaluate the CNS
 Absence indicates motor system disorder
 Persistent Moro response past 4-5 months indicates neurological disorder
 Sucking Reflex
 Touch the mucus membrane inside mouth with finger or object (see if hungry)
 Baby will begin to suck
 Used as a nursing aid
 Breath-suck-swallow
 Continues until baby is weaned
 Rooting Reflex
 Touch side of baby’s cheek near the mouth, when upper lip is touched mouth will open
 Baby will turn head towards the stimulus and open mouth in search for food
 Survival reflex, nursing aid, baby searches for nipple
 Continues for as long as baby is nursed
 Grasp reflex
 Touch the palm of hand or sole of foot
 Baby closes fingers around the hand
 Baby will hold on to mom while nursing
 By 5 months the strength of the grasp diminishes and reflex disappears, foot reflex disappears around 8 month
 Babinski reflex
 Stroke outside of the sole of the foot
 Large toes curl up and spread
 Tonic Neck Reflex
 Turn baby’s head to right side while supine
 Baby will extend right arm and leg to the right while flexing her left arm and leg (fencing position)
 Disappears by 3 month
- Benefits
 Infant-Parent attachment or “bonding”
 Relaxation
 Helps baby feel loved
 Promotes better sleep
 Facilitates body awareness
 Boots immune system
 Sensory stimulation
 Improves skin condition
 Improves blood circulation
 Helps digestion, reduces gas and constipation
 Helps with colic babies
 Balances respiration
 Relief for teething pains
 Help waste elimination
 Enhances neurological system
 Helps build parents’ and baby’s self-esteem
 Helps you learn about your baby (their needs and desires)
 Relaxes parents
 Pleasurable experience
 Stimulates production of oxytocin which is useful as a pain reliever and has a calming effect on the person
 Caregivers report feeling more comfortable and confident in their ability to care for baby
 Parents learn to understand and response to baby’s cue
 Parents learn techniques to comfort calm and sooth their babies
 Provides an additional avenue for close and nurturing contact
 Infant massage is one of the most natural and pleasant methods of providing this important early nurturing and an amazing tool for helps parents become closer to their babies
- When is the Best Time for Infant Massage
 When baby is quiet but alert
 Varies depending on the baby
- Where the Massage should be done
 In a clam quiet space
 Room shoulder be warm and comfortable
 Little distractions
 On a table or floor
- What Equipment do I need
 Any edible lotion – sunflower, safflower, olive, grapeseed
 Soft surface with a blanket or towel
 Extra diapers
- Preparation
 Perform a calming exercise before beginning the treatment on the infant
 Ask for permission from the baby
 Perform the massage
- Contraindications
 Baby has a fever or infection
 Medical issues should be cleared by doctor
 Baby is giving negative cues
 Within 20 mins of eating
 Do not put pressure on the spine, xiphoid process, or skull
- Infant Colie
 Causes:
 Immature digestive system
 Trapped gas
 Reaction to foot including mothers milk
 Allergic reaction
 Air intake when feeding or crying
 GERD/Acid reflex
 Overstimulation
 Signs:
 Intense and prolonged crying
 Abdominal bloating and hardness
 Trapped stomach and intestinal gas
 Acute gastric and intestinal pain
 Results of pain
 Exhaustion/sleepiness
 Stress on parents and baby
 Parent can try:
 Diet alteration
 Creating a soothing environment
 Warmth and skin to skin contact
 Swaddle baby
 Motion – car ride, vibrations
 Rhythmical sounds – running water, hair dryer
 Abdominal massage 2x/day for 2 weeks
- Treatment
 Supine
 Legs
 Do one at a time
 Work from hip to foot
 Flat strokes to the outer then inner thigh
 Squeeze and twist
 Thumb presses to the bottom of the foot, horizontal and vertical
 FTK foot
 “this little piggy”
 Flat hand stroking from ankle to hip
 Rolly Polly
 Leg pumping, hip ROM
 Tummy
 Water wheel
 Thumbs trace under the ribs
 Sun/moon
 Circles run clockwise!
 “I love you”
 “Round and Round the Garden”
 Chest
 Butterfly stroke
 Heart stroke
 Arms
 Do one at a time
 Work from shoulder to hand
 Flat strokes to the outer then inner arm
 Squeeze and twist
 FTK hand
 “this little piggy”
 Flat hand stroking hand hand to shoulder
 Rolly polly
 ARM ROM
 Face
 Strokes across forehead
 Circles to the temples
 Circles to the jaw
 Under the chin up to ears
 Strokes on the cheeks when no longer rooting
 Prone, seated or against the body
 Back
 Flat hand swoop from neck to bottom
 Back and forth (wringing)
 Waterfall – single effleurage
 Neck
 C-scooping the base of the skull
 Legs can also be done in this position
 Pressure is firm but gentle
 Look for positive and negative cues
 Keep strokes slow and soothing if this is the aim, stimulate can be done as well for play time or to waken baby to feed
 Toys can be used
 Sing nursery rhymes
- Babies in the NICU
 Studies have shown that premature infants that have regular touch therapy have an increase in growth and weight of 47% over those who don’t
 Touch relaxation or static contact techniques are used
 Kangaroo care is advised to parents—essential in growth
 Very hard to get in to the NICU as MT
 However, encourage parents to touch their babies!
- Benefits for Children and Teens
 Relief from postural dysfunction
 Reduced anxiety, stress and tension
 Reduce from tension headaches
 Reduce chronic pain
 Treatment of sports injuries
 Improved focus and attention span—can help with ADD and ADHD
 Improved sleep patterns
 Relief from digestive system upset
 Improved emotional and cognitive development
 Reduce depression
 Relaxation and well-being
Amputation handout
- Amputation is a physical and psychological trauma that has a profound influence of the daily life of the individual
- Providing comprehensive rehabilitation services and programs to individuals recovering from an amputation is a complex process that aims to address the functional, emotional, social and psychological needs of each person
- It is generally recognized that in amputee rehabilitation, a multi-disciplinary team approach is required in order to address the individual’s diverse needs
- In today’s medical and rehabilitation practice, that team usually consists of a medical doctor, nurse, physical therapist, occupational therapist and psychological support (either psychologist or social worker)
- At St. John’s Rehabilitation Hospital, a unique feature of the amputee rehabilitation program is the incorporation of Massage Therapy
- Through clinical work and documenting the case-by-case effects and effectiveness of Massage Therapist in out Massage Clinic, a number of benefits of Massage Therapy for amputee population have become recognized
- Overview what are the generally recognized benefits of Massage Therapy
 The body of research proposing and supporting the effects of Massage Therapist is continuously growing
 From research and literature examining the physical and psychological effects of massage therapy, a list (table) of generally recognized effects of Massage Therapy has been acknowledged and commonly sited as indications for referral to Massage Therapy
 It’s interesting to point out that most of the indications for Massage Therapy listed are frequently identified as goals of rehabilitation and very relevant to amputee care
- Table – Indicators for Massage Therapy
 Reduce swelling
 Increased circulation
 Reduced muscle tightness and stiffness
 Reduced scar tissue tightness
 Reduced spasm
 Increased muscle length
 Decreased pain
 Decreased anxiety and stress
 Improved sleep (i.e. duration)
 Increased state of relaxation
- Massage Therapy Intervention for Treatment of Symptoms Specific to Amputation
 The specific symptomatic picture of an amputee client varies from individual-to-individual and is also dependent upon the stage of rehabilitation they are in (for ex., post-surgery, prosthetic training and/or general maintenance program)
 Frequently reported symptoms by amputee clients that have resulted in referral for Massage Therapy treatment at St. John’s Rehabilitation Hospital are as follows:
1. Phantom Limb Pain
 Phantom limb pain is unique to amputee clients
 It is the subjective sensation of pain, not arising from an external stimulus, experience in the part of the limb that is no longer physically present
 Research studies suggest that 70-80% of amputees will experience phantom pain
 Most report it immediately after surgery, however, studies indicate that 40% may experience significant phantom limb pain after the 1 st year
 Amputees have described the phantom pain as burning, stabbing, twisting, cramping, crushing and throbbing
 It is frequently sighted in rehabilitation textbooks for amputee that non-invasive techniques such as massage therapy increase sensory input from periphery (the limb) that may over-ride the brains perception of pain which may provide temporary
or partial relief of the phantom pain
 How this is achieve will depend on each individual amputee and the massage therapists ability to use their palpation and assessment skills to locate areas where the client reports a change in the pain they are experiencing
 Massage treatment may consist of applying massage directly to the amputated end (the stump), to the muscle and soft tissues above the amputation area (the residual limb) or to soft tissues at the proximal end of the effected limb
 A more general massage approach may be appropriate as well with the goal being to reduce stress and anxiety that are recognized as increasing the intensity of frequency of pain
 Reports of massage therapy treatment reducing phantom pain have varying results—that is, for some it has been a great source of relief, whereas for others it has had minimal effect
 It is, nonetheless, a therapy well worth considering in treatment and management of this very specific type of pain unique to amputee clients
2. Residual Limb Pain
 Residual limb is pain experienced at the distal end of the affected limb that remains after the amputation
 The cause of residual limb pain are numerous, such as: tissue damage during surgery, mechanical factors such as poor prosthetic fit, an unprotected neuroma, rubbing of the skin and joint dysfunction
 Additional factors which may contribute to or be the source of the residual limb pain are referred pain fro tight muscles (i.e. trigger points), muscle spasm, adhered scars, poor circulation and swelling
 As noted, soft tissues and muscle that are tight, restricted or dysfunctional can be effectively treatment with massage therapy, thus providing pain relief to the amputee client
3. Desensitization
 Many amputees experience sensitive residual limbs or hypersensitivity of the effected limb around scar areas or muscles, which are hypertonic
 This often results in a cyclical pattern of increased discomfort and pain that often impedes the use and functionality of the affected limb
 Through the direct application of manual techniques to the soft tissues of the residual limb (or stump), massage therapy can be a highly effective method of reducing the sensitivity of the nerves and underlying tissues (muscles, fascia) therefore
reducing the associated pain and discomfort
4. Muscle Tightness, Stiffness and Spasm
 Often, amputees will experience pain symptoms in areas that are not directly associated with amputation
 These structed, referred to as compensator structures, are the muscles and joints that are required to perform new and/or additional functions due to the limitations or inability to perform them with the amputated limb
 For ex., a right upper extremity amputation results in additional demands being placed on the left arm for lifting and personal hygiene
 This imbalance in muscle activity can result in muscular tightness, stiffness, spasm, pin and often leads to the development of repetitive strain disorders in the unaffected limbs
 Such factors will further limit the amputees’ functional abilities and should be addressed early in order to prevent or relieve them
 Assessment to determine the possible cause of the muscular restrictions and reported pain is important in order to develop the appropriate treatment plan
 The massage therapy treatment may consist of trigger point therapy, joint mobilization, and specific massage techniques to the affected soft tissue structures
 Postural education and instruction on home care (for ex. stretching) also become a very important component of the Massage treatment
5. Scar Tissue
 Many amputees have scar tissue in the affected limb associated with surgery or related to the accident
 Scar tissue is tougher, less elastic and often thicker than normal skin and muscle
 Due to its restrictive characteristics, scar tissue can have a negative effect on the neighboring tissues, resulting in stiffness, pain and limited range of motion
 Furthermore, itching and sensitivity of scar tissue is very common, which besides being unpleasant, can reduce the amount of time a prosthetic is tolerated (if it fits over the scar area) or reduced the range of motion of affected joints
 Positive outcomes of scar tissue massage result in reduced tightness, stiffness, pain, itching, an increase in the range of motion of affected and surrounding joints and an overall improvement in movement quality
6. Swelling
 Swelling (or edema) is commonly experience by amputees, especially after surgical intervention, elaborate atmospheric pressure changes, and prolonged prosthetic wearing
 There are specific techniques that can be applied by the trained Massage Therapist (with specific techniques such as Manual Lymphatic Draining that effectively reduces swelling
 Reducing swelling is important for tissue health maintenance as well as removing the excess fluid that can compress on internal structures and result in various uncomfortable sensations (such as tingling or numbness) or pain
 Furthermore, excess swelling can change or alter a prosthetic fit affecting one’s comfort levels when using the prosthetic and overall functionality, impacting the rehabilitation process in a negative way
7. Increased Circulation
 Massage therapy is also recognized for its effect of increasing circulation, systemically and locally
 Good blood flow and appropriate tissue profusion is very important since it is the source of nutrients and waste elimination to and from all tissues
 Many amputees report poor circulation of the affected limb, which results in a cold, and often times painful residual limb
 Winter can be a particular difficult time as the cold weather reduces peripheral blood flow
 Many amputees report it takes a number of hours, if at all, for the residual limb to return to a “normal” temperature and the burning pain to subside
 This may be caused by a number of factors: an amputation affects various soft tissue structures that regulate blood flow into the extremities (i.e. nerves and vasodilation/constriction of arteries and capillaries)
 Another important factor is that after amputation, muscle atrophy to some degree is inevitable since the muscles are not required to work due to missing hand, leg, etc.
 The golden rule applies here: “if you don’t use it, you lose it”
 Since muscle that were directly attached to the missing body part have reduced activity and are smaller due to the atrophy, the muscle pump action, which plays a vital role in blood circulation, is missing
 Massage therapy can be of great benefit in such situations as the kneading and effleurage strokes can mimic the muscle pump action, thus passively and manually moving fluid in and out of the limbs
 Furthermore, massage has a direction local effect on increasing the blood to the area that is being tested (often times seen as hyperemia) on the skin surface
 Poor circulation can also result in a chronically cold residual limb, which is often correlated with an increased level of pain and phantom pain
- Massage therapy can have a short- or long-term effect in providing relief from the above symptoms
- It is important to stress that relief for even a short period of time can have a very positive effect psychologically
- A number of studies suggest Massage Therapy to be highly effective in reducing anxiety, stress and increasing sleep duration
- All important factors that have an impact of quality of life, particular when an individual is involved in a very traumatic accident and is going through an intensive rehabilitation process
- Indicators for Referring to Massage Therapy
 Massage therapy can be of great benefit to amputees in the various phases of rehabilitation and as a preventative therapy in order to ensure a high quality of life for the amputee clients
 There are a number of indicators for referral to Massage Therapy
 Incorporating Massage Therapy into a pain management program is highly recommended due to the direct benefit in treatment of soft tissue dysfunction and circulatory problems, and in the positive effect of Massage therapy on the psychological factors
(i.e. stress, anxiety) which may exacerbate the intensity of the pain being experienced
 It is highly recommended that an amputee receive massage therapy in conjunction with the beginning prosthetic training and ongoing prosthetic use in order to prevent muscle strain, tightness and related pain symptoms that may develop due to the
alteration in posture and biomechanics
 Prevention of decreased range of motion and development of contractures is a major concern due to the negative impacts on prosthetic fit, inability to ambulate with a prosthetic, and development of pain due to soft tissue and arthritic changes
 The best way to prevent loss of range of motion is to remain active and to ensure that the soft tissues are maintained in a state of good health
 Massage therapy intervention if highly beneficial in reducing muscle tightness and stiffness, and maintaining the health of the affected joints
Breast Massage handout

- Massage therapy can be an important and effective treatment approach for the promoting healthy breast tissues
- Breast tissue have therapeutic needs like other tissue, but given the complexities of social symbolism and personal association breasts have for all of us
- Specific and specialized techniques are used to enhance and support lymphatic drainage thus promoting healthy breast tissue
- Breast Massage is indicated for:
 Congestion
 Painful breast
 Discomforts of pregnancy, breastfeeding, weaning
 General drainage problems (family tendency, large breasts, etc.)
 Premenstrual congestion
 Tenderness and congestion related to benign conditions and change associated with involution
 Following diagnostic procedures and recent surgeries, symptomatic relief and promotion of good quality scarring
 Breast trauma
 Restricted, adhered, poorly oriented scars
 Reduction of pectoralis major tone following submuscular implant placement
 Discomforts related to cancer treatment
 Integration of post-surgical changes helping the client become comfortable with her body
 Education in self-examination, self-massage
 Client request for breast massage
 Client has a personal goal of becoming more comfortable with her breasts and having them touched
 Client wants assistance in breast monitoring
- Contraindications
 Lactational mastitis, post-surgical infection, current active infection for any reason
 Specific on-site work at the location of an undiagnosed lump
 Specific on-site work at the location of an abscess
 Use of closed capsulotomy, or any other forceful technique attempting to reduce implant-related contracture
 Direct pressure on the implanted breast manifesting a distorted contour
 Implanted breast with submuscular placement manifesting a distorted contour
 Implanted breasts with submuscular placement manifesting lateral breast and subscapular pain (possible serratus anterior rupture)
 Client cannot, for whatever reason, clarify her wishes and comfortable boundaries
 Therapist cannot, for whatever reason establish professional neutrality
 Client and therapist cannot, for whatever reason, establish open communication
 Client does not give consent, or withdraws consent
- ***Since the breast tissue area is considered a sensitive area according to the CMTO (College of Massage Therapist of Ontario), this requires special consent both written and verbal. Breast massage will not be performed unless client and therapist are
comfortable with the treatment
- Review of Structures
 Muscles
 Pec major, minor, serratus anterior, latissimus dorsi, sternalis, rectus abdominus, serratus posterior superior
 Arteries
 Subclavian, axillary, internal mammary, intercostal (branch of subclavian)
 Veins
 Internal mammary, axillary
 Lymph Nodes
 Adjacent to breast tissue
 Pec major, axillary lymph nodes (level 1-3) supraclavicular, internal mammary
 Fat tissue – defines the breast, insolates lobules, primarily in upper quadrant
 Ducts – drains the lobes and empties into lactiferous sinus
 Ductules – small ducts which lobules empty into
 Nerves
 Supraclavicular, thoracic intercostals, intercostobrachial
 Lobes – glandular tissue division, 15-20, separated by connective tissue and each contain lobules and ducts which open to the nipple (lactation)
 Lobules – functional unit of the breast, milk producing, milk get propelled to nipple via the duct system
 Lactiferous Sinus – reservoir for milk, close to nipple, not large important during breast feeding
 Retromammary Space – between the deep layer of fascia and pec major fascia, allows breast to move over facia covering pec major which helps with drainage of the breast
 Ligaments of Cooper – AKA suspensory ligaments, attach the superficial fascia and extend into the breast tissue to provide a framework as there are no muscle or cartilaginous structures in the breast – no technique will stretch the breast
- Definitions
 Mammary – pertaining to the breast
 Mammary glands – glands of the female breast that can secrete milk
 Lactation – function of secreting milk for breast feeding
 Mastitis (mammitis) – inflammation of the breast, common in women during lactation bu can occur hen no lactation is taking place
 Mastalgia (mammalgia) – pain in the breast
 Mammogram – x-ray of breast
 Mast – prefix meaning breast
 Mastectomy – excision of the breast, full or partial, usually due to cancer. Radical = removal of the whole breast tissue and lymph nodes
 Ominous signs – signs and symptoms that may suggest the presence of cancer
 Lump – palpable dense, nodular mass or other structure change in the feel of the breast tissue
 Cysts – a closed sac or punch which contains fluid, semi-fluid or solid material can occur anywhere in the body
 Involution – changes in the breast due to age (over 35), increase in fatty tissue and regression from readiness of pregnancy and lactation
- Lymph Drainage of the Breast
 The breast in 4 quadrants
 Upper outer – 58%
 Lower outer – 12%
 Upper inner – 17%
 Lower inner 13%
 Lymphatic drainage towards axilla, subclavicular, inguinal and sternal nodes
- Conditions of the Breast
1. Aberrations of Normal Development and Involution (ANDI) very small condition with no cancer risk, so common there is not really a pathology present
2. Fibroadenosis pre-menopausal breast hormonal imbalance, abnormal response to the hormone change bilateral but one side is affected more firm, uneven nodular area sensitive to palpation overgrowth of stromal elements with overgrowth
of glandular epithelium = enlargement of lobules
3. Fibroadenoma unknown cause lobular overgrowth, response to estrogen – increase in size during pregnancy common in women 16-30 firm, rubbery, sharply define round mass that slides between fingers and move easily surgically
removed
4. Cysts a dilated fluid filled sac obstruction of ductile bilateral, asymptomatic but can be painful hard to palpate if not superficial35-55 years old disappear after menopause needle aspiration
5. Abscess localized encapsulate collection of pus bacterial mastitis firm tender lump with local inflammation and edema surgery to drain and antibiotics hydro and lymph work ok but massage if CI’d with surgery there may be drainage tubes
6. Mastitis – lactational related to breast feeding cracks in the nipples form (beginning of breastfeeding) bacteria passes into the ducts, milk warmth and vascularity makes for a good environment for bacterial growth area will wall off and
abscess may form if not treated S&S = pain, hardened tissue, local inflammation and edema, fever and flu-like symptoms Treated with antibiotics, bed rest, frequent emptying of breast, supportive bra, lymph drainage and figure 8 hydro CI =
direct pressure until infection decreases
7. Mastitis = non-lactational Idiopathic Possible cause – progression of duct ectasia, implants, trauma or surgery, viral infection (mumps, RA, lupus), communication with nearby infected structures
8. Duct Ectasia expansion, dilation or distention of ducts very common, mainly elderly women 40-60 inflammation of duct leading to poor clearance of the duct S&S = nipple retraction, discharge of grey/green/opaque/yellow, sensitivity to
cold or pressure, burning/itching, small palpable nodules in sup areola Hydro and massage ok because no contact with nipple or areola
9. Mastalgia pain in breast common symptoms not condition cyclical = related to menstrual cycle, 3-7 days before onset, forming, bilateral non-cyclic = pain from nursing, mastitis, scar tissue from surgery, breast implants, disc problems
(protrusion or DDD), TPs in pec major, minor, scalene anterior, serratus posterior and visceral (heart and lung) referral may also be psychosomatic origin if history of trauma or sexual abuse
10. Duct carcinoma in situ (DCIS) non-invasive ductal carcinoma – not likely to metastasize stays in milk duct can grow to cover small or large does not spread to lymph nodespre-cancerous not life threatening but requires medical
treatment may require mastectomy or radiation 25-50% return with more invasive cancer
11. Invasive ductal carcinoma (IDC) 80% of all breast cancer metastasizes chemo, radiation, surgery amount of tissue removed depends on size radiation after surgery decrease recurrence
12. Lobular Carcinoma in situ (LCIS) considered pre-cancerous starts in lobules bilateral, pre-menopausal biopsy, lumpectomy tamoxifen
13. Invasive lobular carcinoma 10-15% of all breast cancer lobular in origin but spread to surrounding tissue and lymph nodes 45-65 years old not seen in mammogram thickening in upper outer quadrant later stages show puckering and
retraction responds to hormone therapy
- Males and Breast Tissue
 Can get breast condition but rare due to decresed amount of tissue
 800-1000 cases of cancer per year in US
 Prognosis is poor because signs after often overlooked
 Gynecomastia – breast enlargement in men
 Age, decreased testosterone and more influential estrogen
 Fat
 Drug side effect
 Disorders of testicles, adrenals, kidneys, thyroid
 Some lung pathologies
 Breast abscesses typically due to diabetes
- Ominous signs
 Nipple discharge
 Nipple retraction
 Nature of lump
 Changes in breast contour
 Changes in skin-color, texture, temp
 Atypical presentation of breast
 Skin breakdown
 Changes in vein prominence
- Breast Augmentation and Reconstruction
 Increase breast size
 Corrective procedure due to asymmetry or trauma
 Reconstruction following mastectomy
- Breast REdution
 Omen are unhappy with size of breasts of weight o tissue breat musculoskeletal problems in back, shoulder, and neck
 Gender transition
 Incision are smaller than impant and dis done under breat in fold with vertical line up to and around areola
 Drains can be a concer
- Trigger Points Involved
 Scalenes – middle, posterior

Trigger points
Scalenes mid post
Pec major
Pec minor
Sternalis
Serratus
Treatment: supine, hydro, assess both breast for symmetry
Undrape one breast for treatment
Lymphatic drainage
Gentle kneading away from areola/nipple and towards observe for lumps, bumps, and texture changes
Wringing technique and picking up can be used fa
Fascial work to treat scars and restrictions
Friction to scars as long as client has had nodes removed
TP release
Joint play to ribs, clavicle
Re-drape TOM to shoulder girdle
Self care
Self massage
Scar work
Breast exams
Refer if needed
Shoulder exercises if surgery
Treatment frequency
Depends on reason for treatment
30 minutes 1 -2x week
1 x week for scar tissue until resolved

Massage Therapist's Guide To Pathology & Clinical Massage Therapy Understanding, Assessing and Treating Over 70 Conditions

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Massage Therapist's Guide To Pathology & Clinical Massage Therapy Understanding, Assessing and Treating Over 70 Conditions

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Massage Therapist’s Guide to Pathology

Definition Complications Treatment

Demographics Signs and Symptoms Medications

Etiology Massage Therapy Implications

- Conditions of the urinary system

- Tissue Repair/Scar Tissue - Torticollis - Piriformis Syndrome

- Stress - Temporomandibular Joint Dysfunction - Thoracic Outlet Syndrome

- Depression - Adhesive Capsulitis - Cerebral Palsy

- Anxiety - Dislocation 7 Subluxation - Tension Headache & Migraines

- General adaptation syndrome - Pregnancy - Meniere Disease

- Tension Headache - Dupuytren’s Contracture - Chronic Congestive Heart Failure

- Strains - Patellofemoral Syndrome - Hypertension

- Contusions - Periostitis and Compartment Syndrome - Varicose Veins

- Edema / Lymphedema - Plantar Fasciitis - Thrombophlebitis & Deep Vein Thrombosis

- Osteoarthritis - Hyperlordosis – Spondylolisthesis and Spondylosis - Post Stroke

- Fibromyalgia - Hyperkyphosis – Scheurermann’s Disease - Post Heart Attack

- Muscle Spasm - Scoliosis - Chronic Bronchitis

- Tendinitis - Degenerative Disc Disease - Asthma

- Sprains - Infant Massage - Emphysema

- Rheumatoid Arthritis - Diabetes - Cystic Fibrosis

- Ankylosing Spondylitis - Amyotrophic Lateral Sclerosis - Sinusitis (Chronic Rhinitis)

- Other Inflammatory arthritides - Constipation - Amputation

- Gout - Polio - Addictions

- Bursitis - Parkinsons - Lyme Disease

- Fractures - Multiple Sclerosis & Trigeminal Neuralgia - Chronic Pain Syndrome

- Repetitive Strain Injuries - Bell’s Palsy - Prolonged Illness Hospitalization

Fungal Infections of the Skin

Streptococcal infections of the skin

Noncontagious Inflammatory Skin Disorders

Eczema and Dermatitis

Neoplastic Skin Disorders

Skin Cancer – Basal Cell Carcinoma

 Barrier from infection - Described with types

 Damage related to pH, concentration, duration of  Infection

 Alkali burns penetrate through the fatty layer

What are they?

- Systemic effects of a burn are a greater threat to life and include:

3. Reduce circulation of blood

4. Decrease production of urine

5. Diminished immune responses

1. 9% = anterior and posterior surfaces of the head and neck

2. 9% = anterior and posterior surfaces of each upper limb

3. 36% = anterior and posterior surface of the trunk, including buttock

- 70%+ is normally fatal

- Burns are graded by severity:

1. First-Degree Burns (superficial partial-thickness burns) [10%]

 Skin function remains intact

 Healing: 3-6 days (3-10 days), may be accompanied by flaking or peeling

2. Second-Degree Burns (partial or full thickness burns) [25%]

 sensitive to temperature changes, air exposure, and touch.

II. Outer layer: silicone layer, mimics the epidermis

 Dermis or deeper to the subcutaneous layer, may involve muscle or bone

 Hard, dry and leathery

 If muscles is affected may cause kidney damage

 Most skin functions are lost

 Healing: slow regeneration, much granulation tissue forms before epithelium

 Result in shrunken, contracted scar tissue that limits movement