Massage Professionals Article Archive

by Nicole Cutler, L.Ac.

As part of their education, massage therapists learn which pathological conditions could render bodywork as potentially dangerous. However, the rising popularity of massage coupled with our increasingly unaffordable healthcare system means that many bodywork patrons have not visited a physician in a long while. Thus, medical problems often go undiagnosed. Although diagnosing is beyond their scope of practice, bodyworkers must be able to recognize ailments where massage would be unsafe. As such, reviewing the early indicators of appendicitis can help therapists identify and quickly refer out clients in danger of a ruptured appendix.

The Appendix
The vermiform appendix, commonly referred to simply as the appendix, is a 3½ inch long tube of tissue extending from the large intestine. Some doctors believe it serves as a reservoir for immune cells because a high concentration of lymph cells have been found in the appendix. However, those without an appendix don't appear to suffer any negative consequences. Therefore, most physicians believe it to be a non-functioning remnant of an earlier stage in human evolution. Normally found in the lower right abdomen, the appendix becomes inflamed in one of every 15 people.

About Appendicitis
An inflammation of the appendix, appendicitis is a medical emergency that requires prompt surgery for removing the organ. There is a debate regarding why people get appendicitis, but a blockage within the appendix is one of the more likely causes. Several of the suspected reasons for an appendix blockage include:

1. A buildup and hardening of mucus or stool
2. Cancerous tissue
3. A foreign body
4. A swelling of lymphatic tissue

An obstructed appendix leads to local distention, bacterial overgrowth, a lack of circulation and inflammation. Left untreated, an inflamed appendix will eventually burst and spill its infection into the abdominal cavity. The reason appendicitis is an emergency is because infection in the abdominal cavity (peritonitis) can be fatal.

Appendicitis Symptoms
Anytime appendicitis is suspected, immediate action must be taken because the appendix often ruptures within 24 hours of presenting symptoms. Thus, a massage therapist who recognizes the signs of appendicitis should cease massage immediately and arrange for swift emergency care. The most common six indicators of appendicitis include:

1. Pain beginning around the navel, then moving to the lower right quadrant of the abdomen

2. Pain that is sharp and severe

3. Pain that progressively worsens and intensifies with movement or coughing

4. Low-grade fever

5. Loss of appetite, nausea or vomiting

6. Inability to pass gas

While a physician employs many techniques for diagnosis, these four tests can guide a bodyworker to better identify appendicitis:

1. McBurney's Point Test - Rebound tenderness at the junction of the middle and outer thirds of the line joining the umbilicus to the anterior superior iliac spine

2. Rovsing Sign - Pain felt in the right lower quadrant with palpation of the left lower quadrant of the abdomen

3. Psoas Sign - An increase in pain from passive extension of the right hip joint that stretches the iliopsoas muscle

4. Obturator Sign - Pain caused by passive internal rotation of the flexed thigh

Healthcare practitioners are usually weary of jumping to conclusions that would cause their clients to worry. Since appendicitis can be fatal if not addressed immediately, suspecting your client's appendix is inflamed should be disclosed without hesitation. By reviewing these symptoms and tests, massage therapists are best prepared to spot a possible case of undiagnosed appendicitis - and their quick action could end up saving a client's life.

Recommended Study:
Advanced Anatomy and Pathology
Anatomy Review for Professionals

References:

http://www.hcahouston.com/CustomPage.asp?guidcustomcontentid=13B48D6D-F0E9-4C4B-A2C6-300EA1AD74C8, How to Recognize Appendicitis, Retrieved April 18, 2009, HCA Houston, May 2001.

http://www.massagetoday.com/mpacms/mt/article.php?id=10341, How to Say "No" When Your Client Says "Yes," Part III, Ruth Werner, LMP, NCTMB, Retrieved April 19, 2009, Massage Today, October 2001.

http://www.medicinenet.com/appendicitis/article.htm#tocc, Appendicitis and Appendectomy, Retrieved April 19, 2009, MedicineNet Inc., 2009.

http://www.merck.com/mmpe/print/sec02/ch011/ch011e.html, Appendicitis, Retrieved April 19, 2009, Merck & Co., 2009.

http://www.webmd.com/digestive-disorders/digestive-diseases-appendicitis, Appendicitis, Retrieved April 19, 2009, WebMD LLC, 2009.

http://www.wisegeek.com/what-is-the-vermiform-appendix.htm, What is the Vermiform Appendix?, Retrieved April 19, 2009, wisegeek, 2009.

by Nicole Cutler, L.Ac.

According to the American Rhinologic Society, sinusitis is the most common chronic illness in America with an estimated 35 million people affected. Those with repeated bouts have likely tried a range of over-the-counter and prescription drugs for relieving their sinus discomfort. However, sufferers may not realize that a massage therapist could potentially be their greatest ally in their battle against sinusitis.

In the acute stage of infectious sinusitis, massage therapy is systemically contraindicated. However, massage is appropriate for chronic and non-infectious cases of sinusitis, provided the client is comfortable. In general, acute sinusitis lasts for about three weeks; but it can persist for as long as three months. Chronic sinusitis lasts longer than three months and may not immediately respond to conventional antibiotic treatment. Symptoms of chronic sinusitis are less severe than those of acute, but can last for years.

Sinusitis Symptoms
Depending on the stage and cause of sinusitis, the symptoms differ slightly. Sinus symptoms are common during a cold or the flu, but this usually resolves when the infection does. More than just a stuffy nose, sinusitis symptoms are associated with one or more of the following:

· Nasal congestion/discharge that typically is thick and is yellowish to yellow-green.

· Facial pain, pressure, congestion or fullness that is accompanied by other symptoms of sinusitis.

· Symptoms that continue for 10 days or more after the start of a cold or flu.

· Symptoms worsen after five to seven days, or return after initial improvement in a cold.

· Diminished sense of smell.

· Fever accompanied by other sinusitis symptoms.

Other symptoms of sinusitis that usually occur in adults may include:

· Red, bulging or painful eyes
· A persistent cough
· Ear pain, pressure or fullness
· Halitosis (bad breath)
· Dental pain
· Fatigue

Because of the sinus' proximity to the brain, there are some additional symptoms that constitute a medical emergency. These include:

· Eyelid swelling and drooping
· Loss of eye movement or vision changes
· Fixed and dilated pupils
· Severe headache with altered vision
· Mild personality or mental changes
· Soft swelling over a bony area in the face

Specific for a Massage Session
Massage therapists who are working with a client reporting sinusitis must first determine that it is not an acute, infectious case or a medical emergency. Once the client's history confirms this, massage therapists can formulate their session plan. The following four bodywork techniques are known to help sinusitis by breaking up congestion, increasing circulation within the sinuses, aiding the lymph in removing sinusoidal debris and strengthening the immune system:

1. Sinus Massage: To promote drainage and alleviate congestion, perform a sinus massage. You can use these directions as a guide - beginning from the midline, massage in small circles laterally on the forehead out to the temples, the base and sides of the nose out to the cheeks and ears and along the mandible from the chin out to the ears.

2. Acupressure: Utilize the wisdom of Traditional Chinese Medicine (TCM) by applying pressure to the following acupoints - Urinary Bladder 2, Stomach 3, Stomach 8, Stomach 40, Gallbladder 20, Large Intestine 4, Large Intestine 20, Bi Tong, Yin Tang, Triple Warmer 17 and Governing Vessel 24.

3. Cranial Sacral Therapy: Because it moves stagnant cerebrospinal fluid within the bones of the skull, cranial sacral techniques create an influx of circulation, which consequently eases sinus pressure. This technique is especially useful for head, jaw, eye and ear pain from chronic sinusitis.

4. Lymphatic Drainage Massage: Because this manual technique stimulates the movement of lymphatic fluid, it helps the body thin out mucus. Especially when applied to lymph vessels in the head and neck, properly applied lymphatic drainage massage can reduce congestion and sinus pressure.

Whenever a massage therapist is working with clients who have sinusitis, there should be awareness of the following issues:

· Since there is no way to be sure that a client's secretions are non-infectious, be extra vigilant about potential contagion by following universal precautions.

· Affected clients are likely to have difficulty breathing in the prone position. If your session involves back work, make sure it is brief and take steps for your client's comfort.

· Chronic sinusitis sufferers may have inflammation that makes local massage painful. Continually check in with your clients to make sure that sinus massage or acupressure is not causing them pain.

· Bodywork will increase circulation and break up sinus congestion. To help move those toxins out of the body, advise your client to drink plenty of water following the session.

After repeatedly trying to get a handle on their congestion and pain, many sufferers have succumbed to the discomforts of chronic sinusitis. They may be in for a pleasant surprise when massage therapy brings them more relief than their primary physician ever could! By customizing a session with sinus massage, acupressure, lymphatic drainage and cranial sacral therapy, massage therapists can be the most important practitioner a chronic sinusitis sufferer ever entrusts with his or her care.

Recommended Study:
Anatomy Review for Professionals
Cranial-Sacral Fundamentals
Lymphatic Drainage Massage
Shiatsu Anma Therapy

References:

Braun, Mary Beth, Stephanie J. Simonson, Introduction to Massage Therapy, Lippincott, Williams and Wilkins, 2nd Edition, Baltimore, MD, 2007: 183.

http://adam.about.com/care/allergy/allergy_sinusitis.html, Sinusitis, Retrieved August 22, 2009, About.com, 2009.

http://www.american-rhinologic.org/patientinfo.sinusitisqa.phtml, What is Sinusitis?, Retrieved August 22, 2009, American Rhinologic Society, 2009.

http://www.associatedcontent.com/article/191771/how_to_stop_sinus_congestion_now.html?cat=68, How to Stop Sinus Congestion Now, Deborah Dera, Retrieved August 21, 2009, Associated Content, Inc., April 2007.

http://www.chinese-holistic-health-exercises.com/natural-sinus-remedies.html, Natural Sinus Remedies & Sinus Massage Techniques, Retrieved August 21, 2009, Chinese Holistic Health Exercises, 2009.

http://www.firsthealthofandover.com/MBWCranioSacral_Sinusitis.htm, CranioSacral Therapy: Supportive Options for Sinusitis, Retrieved August 22, 2009, FirstHealthofAndover, 2009.

http://www.umm.edu/patiented/articles/what_symptoms_of_sinusitis_000062_4.htm, Sinusitis, Retrieved August 22, 2009, University of Maryland Medical Center, 2009.

by Nicole Cutler, L.Ac.

According to the American Cancer Society, breast cancer is second only to skin cancer as the most common cancer among American women. With a one in eight chance that women in the U.S. will develop invasive breast cancer, early detection has emerged as a life-saving practice. Although not particularly common, inflammatory breast cancer (IBC) is a type of breast cancer that often goes unrecognized until it is in the later stages.

Especially because an estimated 46 million Americans are living without healthcare coverage, there is a great need for educating the public on recognizing the early signs of cancer. While they may not have a primary physician to ask health-related questions of, many who are uninsured will receive a periodic massage. Thus, bodyworkers may be the only healthcare professional accessible to someone with symptoms that could potentially indicate cancer. Massage therapists are not qualified nor are they equipped to diagnose cancer. However, knowing what symptoms represent cancerous red flags can prompt an important referral.

When it comes to educating the public about detecting breast cancer early, great strides have been made. Scanning for lumps via a breast self-exam is the focus of the breast cancer awareness campaign; however, IBC is not characterized by a lump. If familiar with IBC's signs, a massage therapist could be the first to notice that a client is at risk. By advising clients that their breast tissue anomaly may be cause for concern, massage therapists could facilitate an IBC diagnosis at an earlier stage than would have occurred without their intervention.

About IBC
While it is rare, inflammatory breast cancer is a very aggressive type of breast cancer, in which the cancer cells block the breast's lymph vessels. Accounting for one to five percent of all breast cancer cases in the United States, IBC is usually diagnosed in women younger than non-IBC breast cancer.

An advanced and accelerated form of breast cancer usually not detected by mammograms or ultrasounds, IBC requires immediate aggressive treatment and is treated differently than more common types of breast cancer. Inflammatory breast cancer usually grows in nests or sheets, rather than as a confined, solid tumor and therefore can be diffused throughout the breast with no palpable mass.

IBC Symptoms
Because it can occur without a lump, practitioners should be familiar with the following symptoms typical of IBC:

· Heat - A breast that is warm or occasionally hot to the touch.

· Dimpled - The breast and its surrounding skin can take on a dimpled appearance, looking like an orange peel. This texture is not a result of being overweight.

· Nipple Inversion - A nipple that is flat or inverted can indicate IBC, except if an inverted nipple has existed since birth.

· Breast Discoloration - The skin of the breast may appear pink, reddish-purple or bruised.

Other symptoms that could indicate IBC include heaviness, burning, aching, increase in breast size or tenderness that persist throughout a woman's cycle.

Not a Breast Infection
Usually developing quickly, IBC's symptoms may lead people to guess they have a breast infection. Although IBC is commonly mistaken for a breast infection, its symptoms won't go away with antibiotics. Unfortunately, many women (especially those without health insurance) will forego medical assistance and use home remedies to try and quell the discomfort of an assumed breast infection. This is probably the most common reason that IBC goes undiagnosed for so long, making it a much harder cancer to treat.

By being familiar with the symptoms of IBC, massage therapists can serve as public health educators to their potentially affected clients. So, the next time a client asks if you do any kind of massage to help speed the healing of a breast infection, ask more questions. Clients who have self-diagnosed themselves with a breast infection or who have IBC symptoms that have not responded to antibiotics must be evaluated by a physician. Even if your clients do not have health insurance, make sure to share with them what you now know about IBC.

Recommended Study:
Advanced Anatomy and Pathology

References:

http://covertheuninsured.org/, Let's Get America Covered!, Retrieved November 21, 2008, covertheunisured.org.

http://www.cancer.org/docroot/CRI/content/CRI_2_4_1X_What_are_the_key_statistics_for_breast_cancer_5.asp, What Are the Key Statistics for Breast Cancer?, Retrieved November 22, 2008, American Cancer Society, 2008.

http://www.ibcresearch.org/, Home Page, Retrieved November 20, 2008, Inflammatory Breast Cancer Research Foundation, 2008.

http://www.nci.nih.gov/cancertopics/factsheet/sites-types/IBC, Inflammatory Breast Cancer: Questions and Answers, Retrieved November 20, 2008, National Cancer Institute, 2008.

by Nicole Cutler, L.Ac.

Along with the popularity of massage therapy, the percentage of Americans who use complementary and alternative medicine (CAM) each year is growing. On the positive side of this trend, an increasing number of people are taking control of their health to live a better quality life. On the not so good side, many of those interested in CAM are mixing drugs and supplements without the guidance of a knowledgeable physician. Although bodyworkers don't prescribe medications, they may be the first healthcare professional to recognize that their client is dabbling with a risky combination of substances.

CAM Popularity
The likelihood of a person taking supplements without the guidance of his/her physician is steadily rising. In December 2008, the National Center for Complementary and Alternative Medicine (NCCAM) and the National Center for Health Statistics (part of the Centers for Disease Control and Prevention) released new findings on Americans' use of CAM. According to NCCAM, approximately 38 percent of American adults are using some form of CAM. The most commonly used CAM therapy among adults is reported to be non-vitamin, non-mineral natural products. In addition, America's patronage of deep breathing exercises, meditation, massage therapy and yoga is progressively growing.

The Concern
The popularization of CAM modalities has been a major player in improving the public's quality of life. However, many mistakenly assume that its isolation outside of conventional medicine renders their therapy as completely safe. Extensively trained in the cautions and contraindications of their profession, massage therapists are well aware of this common misconception.

When it comes to non-vitamin, non-mineral supplementation (the most popular form of CAM), most Americans act without professional guidance. Published in a December 2008 edition of the Journal of the American Medical Association, a study conducted by the National Institutes of Health and University of Chicago found that at least two million older Americans are taking a combination of drugs or supplements that can be a risky mix. According to the researchers, older men are particularly prone, with one in ten taking potentially harmful combinations.

Study Details
Based on analysis of nearly 3,000 interviews of Americans aged 57 to 85, the older population is especially vulnerable to potential drug and supplement interactions, because their medication use is higher than their younger counterparts:

· Encompassing over 50 million people, 91 percent of older Americans use at least one medication.

· More than half of older Americans use at least five remedies, including prescriptions, over-the-counter medicines or supplements.

Unfortunately, mixing substances without discussing it with a knowledgeable physician or pharmacist could result in disastrous consequences. As a CAM practitioner, massage therapists must be aware of this huge lack of guidance for the general public - especially with their older clientele.

What to Look Out For
As part of the initial history taking process, massage therapists traditionally ask their clients about the medications and supplements they take. Since medications influence massage, this information is crucial to maximizing the session's safety and effectiveness. However, this also means that massage therapists may be the first practitioners to realize their client is dangerously mixing substances. Some common things to look out for include:

1. Blood Thinners With Garlic - Warfarin is a potent prescription clot-fighting drug. Garlic supplements are often taken to benefit the heart and prevent blood clots. However, when taken together, the risk of bleeding is magnified. Excessive bleeding could include bruising easily, hard-to-stop bleeding from the gums or cuts or blood in the urine.

2. Aspirin With Ginkgo - Aspirin also thins the blood and is commonly taken as a clot preventative. Ginkgo is usually taken to enhance memory but it also thins the blood. When taken together, the chance of excess bleeding is increased.

3. ACE Inhibitor With Potassium - Potassium is often taken to compensate for the effects of some blood pressure drugs. Lisinopril, an ACE inhibitor used to lower blood pressure, can cause abnormal heart rhythms when combined with potassium.

4. Statins With Niacin - Also known as niacin, Vitamin B3 is commonly taken to help lower cholesterol. When combined with the cholesterol lowering class of drugs known as statins, the risk for muscle damage is magnified.

5. Diabetes Medications With Ginseng - Ginseng is a popular supplement for reducing stress and boosting energy. However, ginseng may lower blood sugar, which can be dangerous when combined with certain diabetes medications.

6. St. John's Wort - While this supplement is popular to relieve mild depression, it can interfere with the metabolism of prescription antidepressants, birth control pills and anticoagulants.

As confirmed by the recent National Institutes of Health and University of Chicago study, the potential for a risky combination is even greater in people over the age of 57. Keeping this in mind, all healthcare practitioners should pay closer attention to this age group's medications.

By recognizing a potentially risky combination, massage therapists can voice their concerns and advise their clients to discuss their medication and supplement list with a physician or pharmacist. Some people may be aware of the potential for harm and are already being monitored by their doctor, but others may not know of the risks they are creating. As knowledgeable and trusted CAM practitioners, massage therapists are probably in the best position to uncover such risky combinations and make a potentially life-saving referral.

Recommended Study:
Medical Errors
Pharmacology for Massage

References:

http://nccam.nih.gov/news/camsurvey_fs1.htm, The Use of Complementary and Alternative Medicine in the United States, Retrieved December 27, 2008, National Institutes of Health, 2008.

http://news.yahoo.com/s/ap/20081224/ap_on_he_me/med_drug_interactions_2, Millions of older Americans use risky drug combos, Lindsey Tanner, Retrieved December 27, 2008, Yahoo! Inc., December 2008.

http://stayhealthymn.com/print_article.php?articleID=86, A bad mix? Drugs, alcohol and herbal supplements, Kelli Miller, PharmD, Retrieved December 27, 2008, Park Nicollet, 2008.

http://www.bcm.edu/news/item.cfm?newsID=346, Dangerous liaisons: Prescription drugs, certain foods don't mix, Meg Bolton, Retrieved December 27, 2008, Baylor College of Medicine, February 2005.

http://www.webmd.com/migraines-headaches/news/20060719/migraine-depression-drugs-risky-mix, Migraine, Depression Drugs Risky Mix, Miranda Hitti, December 27, 2008, WebMD, LLC, July 2006.

by Nicole Cutler, L.Ac.

Because many of today's careers require constant motion of isolated muscle groups, repetitive motion injuries are one of the most common problems faced by healthcare workers. When such an injury involves the forearm, median nerve compression is a likely consequence. If entrapment of the median nerve is found to be responsible for arm or hand pain, tingling or numbness, a hypertonic pronator teres muscle could be the culprit. By applying several of Doug Alexander's nerve mobilization techniques, bodyworkers can bring surprisingly swift and effective relief to someone with a pronator teres overuse injury.

Pronator Teres Syndrome
Pronator teres syndrome (PTS) is a painful nerve entrapment condition where the median nerve is placed under abnormal pressure by the pronator teres muscle. Functioning to pronate the forearm, the pronator teres muscle attaches to both the humerus and ulna bones near the elbow and then diagonally cross to the radius bone. When stressed, this muscle's hypertonicity can apply pressure on the median nerve, especially where the nerve passes between the pronator teres' two heads.

Pain elicited from a tight pronator teres is usually located in the forearm, wrist and the thenar side of the palmar aspect of the hand. Similar to carpal tunnel syndrome (CTS), pronator teres syndrome typically squeezes the median nerve producing numbness or tingling in the palm, thumb, forefinger and middle finger. Since the well-known condition of CTS also involves compression of the median nerve, many cases of PTS are mistakenly diagnosed as carpal tunnel syndrome. Also occurring from median nerve compression, CTS results from compression of the carpal tunnel - the wrist's fibrous sheath that forms a passageway for the median nerve and hand tendons.

Since PTS typically results from repetitive motions that cause hypertonicity in the pronator teres, activities involving recurring pronation are often behind this problem. Some examples of these motions include:

· Hammering
· Cleaning fish
· Prolonged use of screw drivers or other hand tools
· Overhand motions in racquet sports

Assessing PTS
While PTS and CTS both affect the median nerve and have similar symptoms, there are several differences:

· PTS pain is exacerbated by repetitive elbow flexion, and symptoms arise in the forearm as well as the hand.

· CTS is aggravated by wrist movements, and pain is not experienced as much in the forearm.

· Due to prolonged wrist flexion during sleep, CTS often causes pain at night, while PTS usually does not. (Wrist flexion does not recruit the pronator teres muscle.)

Bodywork Techniques for the Pronator Teres
Overuse injuries from forearm or wrist pronation cause the pronator teres to shorten and become denser, thus increasing the likelihood of compressing the median nerve. Therefore, releasing and lengthening the pronator teres can ease median nerve pressure and relieve PTS symptoms.

In the Institute for Integrative Healthcare's Nerve Mobilization home study course, Doug Alexander cautions bodyworkers that treating the pronator teres can further aggravate an already irritated median nerve. To prevent this, Alexander advises putting the median nerve on slack in two ways:

· proximally via shoulder girdle elevation and slight elbow flexion
· distally via neutral wrist posture

After giving the median nerve some slack, several techniques can release the pronator teres. While step-by-step instructions are included in the Institute's Nerve Mobilization workbook, Alexander says the following three techniques usually unravel pronator teres tension:

1. Contact Inhibition - Inhibitory contact with the hypertonic parts of the muscle can drain pronator teres tension.

2. Post-Isometric Relaxation - Post-isometric relaxation further challenges stubborn pronator teres hypertonicity.

3. Sustained Stretching - Sustained stretching helps to lengthen a previously shortened pronator teres.

Nerve pain can be frustrating, especially for those misdiagnosed with carpal tunnel syndrome. By taking a little extra time to evaluate the pronator teres' involvement in median nerve compression, bodyworkers can provide more targeted, therapeutic treatment. If the pronator teres is hypertonic, protecting the median nerve while combining contact inhibition, post-isometric relaxation and sustained stretching will relieve a majority of PTS cases.

Recommended Study:
Advanced Anatomy and Pathology
Anatomy Review for Professionals
Clinical Massage Therapy
Nerve Mobilization

References:

Alexander, Doug, Nerve Mobilization Workbook, Natural Wellness, 2008.

http://www.chiroweb.com/mpacms/dc/article.php?id=40345, Pronator Syndrome: A Cause of Carpal Tunnel Syndrome, Warren Hammer, MS, DC, DABCO, Retrieved August 19, 2008, Dynamic Chiropractic, July 1995.

http://www.lydiasarticles.com/articledetail.php?artid=60876&catid=360&title=Pronator-Teres-Syndrome-And-Massage-Therapy, Pronator Teres Syndrome and Massage Therapy, Ben Crabtree, LMT, CNMT, Retreived August 19, 2008, 2008.

http://www.massagetherapy.com/articles/index.php/article_id/279, Conscious Bodywork: Unraveling Carpal Tunnel Syndrome, David Weinstock, Massage & Bodywork, October/November 2000.

http://www.massagetoday.com/mpacms/mt/article.php?id=13625, Pronator Teres Syndrome, Whitney Lowe, LMT, NCTMB, Retrieved August 18, 2008, Massage Today, May 2007.