Cancer and Massage

Step 3-Consider Adjusting Massage To Cancer Treatment
The third step is to determine safe practice adjustments by treatment. This requirement leads the massage therapist through the most complex information, and into the most involved clinical thinking of any of the guidelines. Whereas many contraindication lists feature individual entries for individual diseases, the massage therapy profession must move beyond this into how massage affects the systems of the body and therefore a disease of a given body system. Moreover, a condition of one body system can cause conditions in related body systems. Cancer treatments affect many body systems concurrently, and those body systems affect each other in complex ways. 
 
This clinical thinking step can seem daunting at first, but begins quite simply. The therapist determines which cancer treatments were being used, and the list of possible side effects for those treatments. Having integrated this information, it is necessary to determine which side effects prevail in this client. Finally, adjust the massage therapy to those side effects. 
Massage therapists should investigate treatments and their potential side effects on their own before checking with the client and the medical staff to see which are actually in force. Doing this ahead of time will secure a more productive exchange with the physician. Because most contraindications arise from treatments and side effects and not the cancer itself this is a critical step. Generate a list of side-effect-specific modifications in your massage (discussed below, and tabulated in the sidebar). Do all of this before consulting the physician, then run the list of possible concerns by them, to obtain input that is focused and useful. 
  
Some leading concerns for clients in cancer treatment are described below, grouped by the courses of treatment surgery, radiation therapy, chemotherapy and bone marrow transplant. This is by no means a complete list of concerns, only a partial list of some basic principles. References noted along the way are strongly recommended.

Surgery
Cancer treatment often begins with surgery to remove the neoplasm, or tumor. Recent surgery carries risks of conditions of concern for the massage therapist: thrombosis and infection. Massage therapists are not in a position to diagnose these conditions, but should be on the lookout for them. Thrombosis is the formation of a clot within a blood vessel and is one of the most serious concerns for massage therapists in a variety of medical conditions. A thrombus can form within a vein of the thigh or leg, for example, and become a mobile mass, or embolus, if dislodged from this spot. The circulating embolus can then lodge in an artery in the pulmonary circulation. This occlusion of blood flow to the lung is called pulmonary embolism. It is life-threatening.
 
The problem with thrombosis is that, while it can be symptomatic and show clear signs, it can also be clinically silent.19 There are no clear, definitive tests that massage therapists can use for thrombosis, so they need to be on the alert, and understand the conditions that can cause it. Surgery is one risk factor for thrombosis, since the incision provokes an increase in clotting factors that circulate in the blood. Thrombosis risk also increases with inactivity, which is why ambulating (walking) is encouraged post-operatively, where possible. Still, even with ambulation, the sedentary nature of post-operative recovery (fatigue and pain limit mobility) heightens the risk of thrombosis. Moreover, some cancers themselves, such as lung, pancreas and gut, pose an increased risk of thrombosis.²⁰
 
Concern about thrombosis contraindicates local and regional massage around an incision site after recent surgery. Massage of the lower limbs also is contraindicated due to possible pooling of blood there, which creates an environment favoring clot formation. Because of this very serious possibility, massage therapists should always consult the client's physician to determine when it is safe to approach these areas. They should ask specific questions of the physician about the risk of thrombosis, and for how long to avoid the low limbs and the region of the incision site. Nursing staff can supplement this information. Get physician orders after surgery, and written permission to massage the lower limbs before doing so. 
 
Infection is another post-operative concern and contraindicates general massage. If infection sets in at the incision site, it is usually within the first few days after surgery. Signs of infection include fever and redness, pain, heat or swelling at the incision site. Without special training in scar work and permission from the physician, a massage therapist should not be working near the incision site at all. If the client shows any signs or symptoms of infection, postpone any circulatory techniques or use of pressure and refer immediately to the client's physician for follow-up. Document this referral in your records, or in the hospital chart if you are approved to use it. Post-operative infection is an issue in the first few days after surgery. It is potentially very serious if untreated, but treatment is usually straightforward and patients usually respond to prescribed antibiotics.
 
An incision site presents the massage therapist with a local contraindication unless they are well-trained in working with adhesions and have the physician's approval. With appropriate training, hands-on practitioners may be able to work directly on an incision site to prevent scarring. Massage therapists in training for scar work should question their instructors closely about possible contraindications and guidelines for timing of treatment after surgery. Skilled, appropriate massage at the incision site can promote healing.²¹ But most massage therapists with basic massage training need to steer clear of the incision site, especially a recent one, for several reasons. It is at or near a current or former tumor site. It is actively healing, a process which includes clotting, and it may still be inflamed and irritated. It may be a site where extensive tissue has been removed, leading to complex healing and tissue changes.
Lymphedema is a common concern after surgery in which lymph nodes have been removed. (It also can occur after radiation therapy.) Given obstructions to drainage, lymphedema arises in the limb that is distal to the nodes removed. This condition often tempts massage therapists to massage it in order to help circulation and drain the area. The problem with this is that standard Swedish massage, or any massage with pressure, can also easily aggravate existing lymphedema. Usually lymphedema comes and goes, and a client may be on watch for it after surgery. Activity such as gardening or typing may bring it on in a person's arm after mastectomy or even lumpectomy. Plane travel, cuts or infection in the affected limb also can bring it on. 
 
Even if there has been no previous edema, any time there has been surgery at proximal lymph nodes, the therapist should only work under a physician's supervision. Massage therapists working independently, using regular or deep pressure on the limb of the affected side, risk precipitating an episode of lymphedema. A client's physical therapist or trained lymph drainage therapist will be working with a combination of light, carefully choreographed massage, sequential compressions, and bandaging to reduce or eliminate edema. A massage therapist doing other techniques should be working in concert with one of these practitioners rather than in opposition.
 
Another risk of surgery is reduced function, due to inflammation and scar tissue formation, pain and medical devices. Range of motion at the joint can be impaired, as well, due to muscle spasm. Again, specialized massage therapy for scar reduction may be applied. But even without this training, most massage therapists can reduce muscle tension in the associated muscles and support the client's movement. One benefit of movement is developing and maintaining strength in the area. In this way, massage therapy can provide important adjunctive care. It is critical to obtain physician approval before proceeding with massage regional to an incision site. List the specific muscles in the affected area that you would like to massage and describe your techniques clearly, preferably in writing, to the physician as part of the approval process.
Massage therapists should learn all they can about the client's surgery (or surgeries), how recent, any complications, whether nodes were removed, and how well the client has healed. Once they have gathered this information from the client and devised a preliminary massage session plan, the client's oncologist should be consulted for permission. The massage therapist should run their concerns by the oncologist, corroborate information received from the client, and get input into the session design before carrying it out.