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Is Massage Really Wise For Neuropathy

Today's post from painscience.com (see link below) warns about the possible disadvantages of massage therapy. Many people with neuropathy symptoms somehow assume that massage will help them feel better and in many cases they do but you need to go to a massage therapist who knows what he or she is doing. The idea that you may come away with symptoms that are worse than before should be enough to make you think about whether a good pummelling is really good for your nerves or not. Gentle massage may well be very effective in calming down painful nerve areas, or generally making you relax but the minute the masseur goes for deep tissue and joint massage may be the moment you ask how much experience he or she has with neuropathy. You probably know yourself, if you've tried massaging your neuropathic feet. Half the time you can't feel anything due to the numbness but the moment you push just that little bit too hard to relieve the burning or tingling, you can be suffering for days. Always best to go to a qualified masseur with relevant experience, or else the happy ending may not be as happy as you thought (goes for all kinds of massage!!)
 

What Could Possibly Go Wrong With Massage?
Rare but real adverse effects of massage therapy, especially “deep tissue” massage
updated July 16 2014 by Paul Ingraham, Vancouver, Canada bio

People think of massage therapy as a “safe” therapy, and of course it mostly is. But things can go wrong, or at least a bit sour. While serious side effects in massage therapy are extremely rare, minor side effects are downright common. A 2007 survey of 100 massage patients1 found that 10% of 100 patients receiving massage therapy reported “some minor discomfort” in the day following treatment. This would mainly be a familiar slight soreness that is common after a massage, known as “post-massage soreness and malaise” (PMSM) — and I’m surprised only 10% reported it. The massages they were getting must have been quite gentle.2

Interestingly, 23% reported unexpected benefits that had nothing to do with aches or pains. (Benefits for musculoskeletal problems were not documented.)

This study is underpowered. It cannot and does not rule out rare and/or serious side effects of massage therapy, which do exist. You could probably do several studies of 100 patients without encountering a single nasty situation. But what if you surveyed 1,000 patients? Or 10,0000? Massage is not completely safe — what is? — and other adverse effects would almost certainly turn up in a big enough survey. Nevertheless, according to one of alternative medicine’s most vigorous critics, Dr. Edzard Ernst, “Serious adverse events are probably true rarities.”3 And yet, reviewing the literature again in 2013, Ernst and Posadzki found at least 18 reported examples of “moderately severe” reactions to normal massage, especially of the neck.4
When massage goes bad

So what could possibly go wrong? Massage can…
directly cause new injuries (mostly quite minor, but not all)
aggravate existing injuries and chronic pain problems
distract patients from more appropriate care
mildly stress the body And don’t forget, of course, that that pointlessly draining your wallet is another kind of pain. If someone spends $5,000 on massage therapy that has only a minor therapeutic effect, or none at all, is that an “injury”? It’s an insult, at the least!

In my decade (2000–2010) as a massage therapist, I met many patients who had been harmed by massage therapy to some degree — fortunately, mostly just expensive disappointments and minor backfires, but quite a few more serious cases too.5 

Sensory injury

A painful, alarming sensory experience can actually dial up pain sensitivity — even long term.6 Furthermore, vulnerability to this awful phenomenon is much more common and significant in desperate patients who already have chronic pain — so they seek and tolerate intense therapy. People experiencing pain system dysfunction can have minor & major setbacks in response to excessively painful massage.

The experience of pain is affected by many factors, including emotional and psychological ones. People in chronic pain usually experience some degree of pain neurology dysfunction, and a breakdown of the relationship between how bad things feel and how much is really wrong. That breakdown can be seriously worsened by threatening sensations. Thus, people experiencing pain system dysfunction can have minor and major setbacks in response to excessively painful massage.

One of my readers suffered this kind of disaster. She was injured by “fascial release” therapy, a style which is often too intense and may focus on treating connective tissues to the exclusion of considering the patient’s comfort and nervous system.

I may have been too aggressive with a few patients over the years. I never did serious harm this way as far as I know, but I’m sure that I occasionally did more harm than good. This failure was due entirely to my ignorance of pain science: despite being an unusually well educated massage therapist, I simply did not know that an intense massage could change pain sensitivity itself. Does your therapist?
Pain is Weird Pain science reveals a volatile, misleading sensation that is often more than just a symptom, and sometimes worse than whatever started it ~ 9,000 words
The Pressure Question in Massage Therapy What’s the right amount of pressure to apply to muscles in massage therapy and self-massage? ~ 4,500 words
Poisoned by massage

Excessive pressure probably has another predictable outcome: a light poisoning. Seriously.

For example: an 88-year old man collapsed the day after an unusually strong 2-hour session of massage therapy.7 He had too much myoglobin in his blood, and it was poisoning his kidneys and generally making him feel rotten. It’s not a sure thing that his condition was cause by the massage — but it is quite likely. It is almost certainly a perfect example of one of those rare but serious complications of massage. Another case study comes up below.

Ironically, many people believe that massage is a detoxification treatment, but in fact it’s probably the opposite. Ironically, many people believe that massage is a detoxification treatment, but in fact it’s probably the opposite. Post-massage soreness and malaise is probably caused by mild rhabdomyolysis (“rhabdo”): poisoning by the waste products of injured muscle.

True rhabdo is a medical emergency in which the kidneys are poisoned by myoglobin from muscle crush injuries. But many physical and metabolic stresses cause milder rhabdo-like states — even just intense exercise, and probably massage as well. There are many well-documented cases of exertional or “white collar” rhabdo, and there is a strong similarity between PMSM and ordinary exercise soreness. A rhabdo cocktail of waste metabolites and by-products of tissue damage is probably why we feel a bit cruddy after all biological stresses and traumas — including massage, sometimes.

PMSM is just an unavoidable mild side effect of strong massage. And for a few more vulnerable patients, it could actually be a little dangerous.
Poisoned by Massage Rather than being “detoxifying,” massage may cause a modestly toxic situation in the body ~ 4,500 words 

Other examples of massage wounds

The neck is not generally a fragile structure, but it is in some people. Another serious example of an adverse effect of massage is what happened to my barber — either a brain stem injury or mini-stroke caused by careless massage of a vulnerable neck. One of my own patients was injured the same way by another therapist, vomiting and retching for hours afterwards (a nasty symptom of brain stem impingement, or ripping of an artery going to the brain). I came close to doing this to another patient — that’s three examples of such patients in my career — but I’m proud to say that I spotted the warning signs and avoided disaster.

A weird case of brain artery damage (extracranial internal cartoid artery dissection, specifically) was reported in 2004 by the Southern Medical Journal: a 38-year-old woman gave herself a stroke by using a vibrating massage tool for long and too hard on her neck.8 Obviously such an incident has little to do with professional massage. Nevertheless, it demonstrates that the arteries of the neck are a little bit fragile — and I have no doubt that there are poorly trained or incompetent therapists out there would might get carelessly exuberant in this region, while trying to treat the scalenes: see Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain.

Another weird, extreme case study paper tells the horror story of one person’s awful experience with a severe reaction to (apparently) infrared heat and massage therapy.9 The trouble started after several treatments. His neck and arms were swollen, the pain became “unbearable,” and his “serum muscle enzymes were increased” — which means some degree of rhabdo, which implicates the massage itself as a significant mechanism of injury. Massage is not likely to “blame” for the incident, though — it was probably interacting with some unidentified vulnerability in the patient, such a muscle disease or a complication caused by a medication. Clearly massage and heat alone do not normally cause such severe side effects! Nevertheless, the potential for very unpleasant interactions exists.

“Alternative therapies may have serious complications, and patients usually do not report them unless asked specifically,” the authors point out.

I am one-degree of separation from a patient whose femur (the big leg bone!) was fractured by a massage — it was a weak and injured femur already … but wow!

Nerves aren’t nearly as vulnerable to pressure as people generally think — most of them can actually take quite a licking and keep on ticking without a single symptom — but they aren’t invulnerable. And I once caused a nerve injury myself: it was a minor injury, but it did — augh — result in weeks of aggravating discomfort for my client. The Archives of Physical Medicine & Rehabilitation reported a similar spinal accesory nerve injury: “a rare and illustrative case of spinal accesory neuropathy associated with deep tissue massage leading to scapular winging [the shoulder blade sticking out] and droopy shoulder as a result of weakness of the trapezius muscle.”10
What Happened To My Barber? Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers ~ 2,750 words 

Lessons for professionals and patients

These are rare but real incidents. Healthy people are unlikely to be injured by massage. Most of dangers are related to undetected vulnerabilities, and they emphasize the importance of alternative health professionals being trained to spot the scary stuff. The measure of a health professional’s competence is not what they do with relatively healthy patients, but whether they have the training and humility to realize when they are on thin ice.

Manual therapists need to know that the most important part of their job is the smart management high-risk situations that they may see only a handful of times in their entire career. It’s like being on guard duty: 99.9% of the time, nothing bad happens. But how do you handle a curve ball when it finally comes?

Consumers need to know that cocky, overconfident therapists who trash-talk “mainstream” health care are all-too-likely to be ignorant of critical warning signs, or dismissive of them. The skeptical salamander thinks these therapists shouldn’t be allowed to touch anyone. See Missing Serious Symptoms.

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of ScienceBasedMedicine.org. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.




Notes
Cambron JA, Dexheimer J, Coe P, Swenson R. Side-effects of massage therapy: a cross-sectional study of 100 clients. J Altern Complement Med. 2007 Oct;13(8):793–6. PubMed #17983334. BACK TO TEXT
 
Indeed, that seems very likely given the context. I doubt they would test painfully strong massage on 100 people without mentioning the intensity. However, painfully strong massage is quite common “in the wild.” Certainly intense massage is unusually common here in Vancouver, where there’s a regrettable professional predeliction for it. BACK TO TEXT
Ernst E. The Safety of Massage Therapy. Rheumatology. 2003;42 (9):1101–1106. PubMed #12777645. PainSci #54834.

Is massage safe? Researchers attempted to answer that question. Four databases were reviewed; all articles which reported adverse effects of any type of massage therapy were looked at. In the end, 20 reports were looked at. “The majority of adverse effects were associated with exotic types of manual massage or massage delivered by laymen, while massage therapists were rarely implicated.”

The conclusion was that, while not entirely risk free, “serious adverse events are probably true rarities.” BACK TO TEXT
Posadzki P, Ernst E. The safety of massage therapy: an update of a systematic review. Focus on Alternative and Complementary Therapies. 2013;18(1):27–32. PainSci #53974.


OBJECTIVE: To update a systematic review evaluating the safety of massage therapy.

METHODS: A literature search was carried out using four electronic databases for the period December 2001 to May 2012. All articles reporting adverse effects of massage therapy were retrieved. Adverse effects relating to atypical massage, aromatherapeutic massage oil or ice were excluded. No language restrictions were applied. Data were extracted and evaluated according to predefined criteria.

RESULTS: Seventeen case reports and one case series were published since our previous review. The reported adverse effects comprised acute paraplegia and abdominal distension, bladder rupture, bilateral cerebellar infarction, cervical lymphocele, cervical cord injury, cervical internal carotid and vertebral dissection, chylothorax, haematuria, interosseous nerve palsy, myopathy, perinephric haemorrhage, rhabdomyolysis, severe headache, blurred vision, paraesthesia and focal motor seizures. In the majority of the reports, a cause–effect relationship was certain or almost certain. Serious adverse effects were most commonly associated with massage techniques applied to the neck area.

CONCLUSION: Evidence suggests that massage may occasionally lead to moderately severe adverse effects. BACK TO TEXT
 
Several dozen at least who experienced minor negative effects and a lighter wallet. I recall only about dozen or so having really poor experiences, mostly aggravated chronic pain. Only a handful of those were obviously significantly injured by massage. But those were sad cases. BACK TO TEXT
 
Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010 Oct;152(2 Suppl):S2–15. PubMed #20961685. PainSci #54851.

Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. That sensitization is called “central sensitization” because it involves changes in the central nervous system (CNS) in particular — the brain and the spinal cord. Victims are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other people.

For a much more detailed summary of this paper, see Central Sensitization in Chronic Pain. BACK TO TEXT
 
Lai MY, Yang SP, Chao Y, Lee PC, Lee SD. Fever with acute renal failure due to body massage-induced rhabdomyolysis. Journal of Nephrology, Dialysis and Transplantation. 2006 Jan;21(1):233–4. PubMed #16204282. PainSci #54301. BACK TO TEXT
 
Grant AC, Wang N. Carotid dissection associated with a handheld electric massager. South Med J. 2004 Dec;97(12):1262–3. PubMed #15646768. BACK TO TEXT
 
Tanriover MD, Guven GS, Topeli A. An unusual complication: prolonged myopathy due to an alternative medical therapy with heat and massage. South Med J. 2009 Sep;102(9):966–8. PubMed #19668045. BACK TO TEXT
 
Aksoy IA, Schrader SL, Ali MS, Borovansky JA, Ross MA. Spinal accessory neuropathy associated with deep tissue massage: a case report. Arch Phys Med Rehabil. 2009 Nov;90(11):1969–72. PubMed #19887226. BACK TO TEXT

https://www.painscience.com/articles/whats-the-harm.php

Massage Helps People with HIV and Neuropathy

Another interesting article from the Australian, positivelife.org.au (see link below) describes one man's way of giving back to the community. Someone to massage your hurting body for you seems to me a fantastic way to make you feel better. No 'happy endings', or commercial rip-offs, just careful massage carried out by someone who knows what he or she is doing. It's an idea that should be promoted in as many places as possible, though finding the volunteers with the right intentions might be easier said than done. Hats off to Mr Page.

Touching bodies - and souls
by Greg Page - •This article was originally published in the Oct-Nov 2011 edition of Talkabout

Greg Page reflects on what leads him to donate an hour of his time each week to massaging HIV+ clients.

Once a week I do a volunteer massage for HIV+ patients. As a trained massage therapist with over five years of experience, I'm constantly asked the same question by my clients, who are almost invariably middle-aged men: "Are you one of us?" By which they actually mean, "Are you HIV positive too?"

There is always a real sense of relief in their voices when I reassure them that, yes, I understand the nuances of niggling neuropathy, constant painful twinges and strange, doctor-confounding ills that can befall a person who is a long-term sufferer. You see, I'm a massage therapist who has also been HIV+ now for eight years.

I actually began my training about six years ago at a course offered by an instructor who wisely believed it a good idea to give newly-HIV+ men an insight into their bodies, what makes them tick and what makes them tick better. Massage therapy is a skill for life, as well as a skill that can help and heal, for both the giver and the receiver. My massage training took about six months to complete. It included two hours per week of intensive anatomy lessons, with a book to practice with, not a body, in case you're wondering. I had to learn multisyllabic phrases and convoluted names for parts of the body that normally only specialist doctors would know off my heart. In my course, of the 10 HIV+ men who began the training, only six finished. One disappeared never to be seen again, one became a crystal addict, another decided it was all too hard and another took his first three months of training and turned it into a business, touting himself as the "massage therapist who gives happy endings".

96 percent

I finished my training with a 96 percent score, something I was very proud of, although I wasn't top of my class – a hunky Canadian-born guy scored 99 percent (though I did better than him in the practical assessment!)

Over the course of our training, our group constantly practised on each other, but the biggest challenge we faced wasn't concentrating on what we were doing or making sure we were doing it properly. It actually came when we had to massage a group of HIV+ women.

None of us was familiar with women's bodies and it was a truly eye-opening moment. As gay men we are generally so unfamiliar with the curves and nature of a woman that it took some major readjustment for us as massage therapists to accommodate them. It was a good lesson in what was to come as a masseur – everybody is different and some bodies are more different than others.

Although our course had been offered free, the deal we all agreed to was that on successfully completing the course and qualifying, we would have to allocate 60 hours of free massages to community services. Somehow for me that 60 hours has now become six years of offering my services to the HIV+ community.

Troubled bodies and minds

Most of the men I massage are relatively advanced in their HIV+ prognosis. Some have lived with it for over 20 years. One man told me he knows he has been positive since 1980, if not before. He witnessed his entire circle of friends, lovers and ex-lovers die before his very eyes in those early first years of AIDS. He is now somewhat bitter, quietly angry and rather fed up with life. The massage I give him every few weeks helps alleviate the pain not only in his riddled body, but his troubled mind.

The one question I always like to ask my clients is what their job is. Some are still working and on my bench, laid out in front of me, I've had professions as varied as shopkeeper, actor/model, ad agency boss, librarian, historian, labourer, insurance man, personal trainer, healthcare worker, recovering addict and full-time nudist. Some of the men have been on sickness benefits for so long they can't even contemplate the idea that they could once again be valuable members of the workforce. They never thought they would live this long, let alone be healthy enough to return to the jobs they assumed they were leaving to go and die. The meds changed things and kept them alive. Some of my clients are happy about this, yet others feel somehow guilty they survived. Some like to talk about how they feel, with the massage helping to ease their suffering and their inhibitions, while others prefer to just simply enjoy the serenity of being able to have their body caressed and touched like they haven't been touched in a long time.

It's a powerful reminder to me as to how important the sense of touch is. Although we often think seeing is believing, through my work with clients on the massage bench I have come to see that the greatest gift I can give to those who are suffering, or who have suffered hard, is simply that of a compassionate, caring touch.

No words

Sometimes there are almost no words before, during or after our one-hour sessions. Some people choose to lose themselves for the 60 minutes, regaining a connection with their body tissue that years of toxic medication, intensive doctor prodding and a raft of severe illnesses have left tenuous and tense. If I can help ease that tension, then I feel my work has been a success.

Generally my clients leave after the massage feeling the best they've felt in a long time. "I feel like I'm floating" is a piece of feedback I receive constantly. That's when I know that not only have I done a good job, but I made the right choice in volunteering my services, rather than charging a fee and making it my full-time profession.

It's a shame there are not more people from the HIV+ community who get involved in complementary therapies. Not only does it help you give something back, but also gives you a link to the past of the AIDS epidemic. It's a way to help ease those survivors through the new era of manageable chronic illness.

More alive

One week recently I massaged a blind man who brought in his guide dog, which sat quietly as his owner groaned his way through our session. It was as if my client had not felt a human hand near his weakened body in a long time. He shook my hand firmly afterwards and I could tell he felt more alive.

I truly get a strong sense of satisfaction when I finish my volunteer session each week. Not only because I know I'm doing something good for others, but because I'm actually doing something good for myself. You should try it some time – you might find it as soul-enriching as I do.
Greg Page

http://positivelife.org.au/talkabout/2011/oct-nov/touching-bodies-and-souls

Foot massage for neuropathy

These two videos are a follow up to yesterday's post about caring for the feet. You may need to ignore the corny background music and the slightly New Age feel, because the techniques you see here are perfect for neuropathic feet.

You may be able to do some of these techniques on your own feet but it will be ten times better if you can get a friend to do it for you (after he or she has watched the videos!), then you can relax completely. The whole process would be better after cleansing, both for the benefit of your masseur but also because the feet will be both stimulated and relaxed, so that the massage can have maximum effect. After the massage and drying off, try some gentle exercises to keep the feet supple.

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