Cancer and Massage
This therapy uses beams of radiation to act directly on tumors to shrink them or prevent their growth. It also can be used over the whole body to treat certain cancers or to prevent rejection of a transplant. It should be noted that most radiation techniques expose only the patient, not others around them, to radiation. The massage therapist needn't fear exposure to the radiation, unless it is delivered in implants or through radioactive iodine; then contact is prohibited until exposure risk has subsided.
The most obvious concern for massage therapists massaging clients in radiation therapy is to take care with radiation-treated areas. Skin changes include redness, dryness and irritation. In addition, itching can cause people to scratch, so the skin may be open and irritated. Patients in radiation therapy receive careful instruction from medical staff on the care of the skin, and massage must be within these guidelines. A general guideline for massage therapists is to avoid massaging irradiated sites. Think of it as a burn, much like a sunburn. Very light contact with the area may be possible if the client can tolerate it and medical staff approves. Untimely application of the wrong lubricant could interfere with the therapy by coating the skin so that the effects of the radiation beam are altered.22
If large areas of the body, such as the abdomen, are irradiated, fatigue is more likely to be a side effect. See below, adjust massage to client's stamina, for guidelines in this case. Massage should be gentle to avoid further challenge to a fatigued client.
If lymph nodes are damaged by radiation, lymphedema is a risk. As is true after surgery (see table), it is necessary to work with client's medical staff to determine how to treat the limb on the affected side.
Nausea and vomiting can occur with radiation therapy, too, but usually occurs with upper abdomen radiation or total body irradiation.23 If nausea is present, massage therapy, range of motion techniques and other passive movements such as rocking or jostling or stretching are contraindicated, to avoid proprioceptive challenge to the client. When fighting nausea, it can be difficult to have one's body moved through space.
Radiation may be directed at a very small focus area, over large areas such as the whole abdomen, or even over most of the body. A client undergoing total body irradiation, for example, in leukemia treatment or as part of the procedure for a stem cell transplant, is undergoing one of the most challenging cancer treatments available. Effects of radiation will be visible over large areas of the body. See the entry below, under bone marrow transplant, for guidance.
Chemotherapy is strong treatment, affecting energy level, digestive function, blood cell production, and even some nerve function. It primarily affects fast-growing cells, and therefore used against the rapidly-dividing cells of tumors. It also can be detrimental to other fast-growing cells in the human body, including those responsible for hair growth, those lining the digestive tract, and blood cells.
The first three entries in the accompanying table under chemotherapy result from the effects on blood cell production. White blood cells (leukocytes) and platelets (thrombocytes) are especially affected by this growth-inhibiting property of chemotherapy.24 Two conditions, leukopenia and thrombocytopenia, reflect poor cell numbers and can prevail during chemotherapy. If a cell type is in poor supply, its function is compromised.
In the case of leukopenia, resistance to infection is diminished, so it is extremely important for a massage therapist and any other person sharing space with the person to be free of infection. This means that therapists should avoid contact with a client if the therapist or the therapist's family members are ill.25 It also means that clients may need to be scheduled during low-traffic times in the massage therapist's office. The massage therapist should consult the client's medical staff for a sense of white blood cell levels and corresponding compromised immunity.
Low platelet counts direct a different course. Here, clients may bruise or bleed easily, since platelets are responsible for clotting. Even slight pressure from resting against hard furniture may bring about severe bruising. The therapist needs to adapt the pressure of the massage in kind, to avoid damaging tissue. The severity of bruising and bleeding, corresponding to the platelet count, will affect how much the therapist needs to adjust the pressure. Get a sense of this severity from the client's medical staff and ask the client if their activity is restricted or cancer treatment has been modified due to this condition.
Finally, anemia can be a side effect of chemotherapy and result in fatigue, dizziness when standing up, shortness of breath, intolerance to cold, and other characteristic symptoms. Adjustments in massage include gentler pressure to accommodate the fatigue, and warm surroundings. But this is one example where the massage therapist's questioning may take off in a different direction, since prolonged, severe anemia can create a heart condition, as the body attempts to compensate for its oxygen-poor blood by pumping it faster. Investigate the possibility of a heart condition in anemia, whether it is due to the cancer itself or to cancer treatment. Then, with the help of the physician, explore the massage implications of this, as some references list it as a contraindication to massage therapy.26
Skin changes occur during chemotherapy. Dryness, rashes and touch sensitivity and "prickliness" all contraindicate local and regional massage if it causes discomfort. Often chemotherapy causes skin reactions that look like infections but are merely reactions to the medication. Check in with the client and medical staff about the origins of any skin changes, as they can change from day to day.
Open skin lesions contraindicate local and regional massage follow standard precautions against infection so you don't introduce lubricant or common skin flora from your hands or the client's skin into the openings. Consult medical staff about the use of gloves if you work with someone with open, weeping lesions. Even if you avoid the region itself, as you should, fluid from open lesions can be transferred elsewhere on the body by sheets, fingers, etc.
Hair loss (alopecia) is a potential side effect of chemotherapy. As the most visible and striking indicator of cancer treatment, it can hold profound emotional significance for the client. Hair loss can be limited or widespread, depending upon the treatment. Usually body image is deeply affected by this experience. The massage therapist can play an important role by touching the client's body with care and accepting the client's appearance without judgment.
With hair loss, the primary caution in force is the need to respect the client's wishes about having their head exposed or touched. A client may want to keep their head covered with a wig or scarf during the touch session. Whether working around a headpiece, or working on the bare skin, the therapist should be prepared to fully remove oil or lotion so that it doesn't damage the hairpiece, hat or scarf. Clients affected by alopecia also may have irritation on the scalp, or it may be irritated as the hair begins to return. It is important to question the client about scalp condition (itchy, irritated and Òprickly, are all possibilities) and their desire for touch in this area. Therapists need to navigate this issue with care and sensitivity, so that the benefits of skilled touch on the body image may be realized.
Mouth sores can occur from chemotherapy and can be quite uncomfortable. In addition, they require close care and attention from the client to avoid infection. The massage therapy session should be planned so that these sores aren't aggravated. For this reason, check in with the client to see that the face cradle does not exert pressure or tug on the sore areas. Jaw or cheek massage may be prohibited for the same reason.
Fever contraindicates any vigorous or circulatory massage therapy. Traditional lore in massage therapy has it that circulatory massage may worsen any infection that is present, and fever, though a side effect of some chemotherapy, also may signify infection. Whether massage could spread infection may not have scientific basis yet, but the contraindication rests on simpler matters: Fever is consuming, and the body needs its resources to heal. Work simply and gently and do not burden the client. Also note that medical referral is necessary if the client shows a fever. Document this referral in your own notes.
Digestive and eliminative functions are influenced by chemotherapy. Nausea and vomiting are likely and require massage therapy adjustments. First, general circulatory massage probably is contraindicated during nausea, as is any other strong stimulation such as range of motion or jostling. Passive movements challenge the body's proprioceptive functions and are inappropriate during nausea. Second, unscented oils or lotions may need to be substituted for scented products, especially around the time of chemotherapy treatment. Be certain the client is hydrated, so that fluid and electrolyte balance is intact before you begin massage. Also, locate easy access to a bathroom. Other eliminative problems such as diarrhea and constipation may be present, and are addressed briefly in the table.
One common outcome of the above is extreme weight loss, or cachexia. This presents specific issues for the massage therapist. First, the client's stamina is often affected, whether due to the cachexia, the causes of it or other phenomena, the massage therapist's response should be the same to be gentle and not overwhelm the client's resources. More specifically, pressure may need to be reduced. Nerve and vascular endangerments are no longer protected by as much adipose tissue or muscle as they once were, so be gentle on these sites. In addition, positioning may need to be adapted to more prominent bony prominences, and the client can easily become sore in one position. Give your table extra padding.
Various nervous system phenomena arise as side effects of chemotherapy. These are due to the effects of the medications on nerve function. Central nervous system pathways can be affected as well as peripheral ones. Seek information from the treating physician and client about these concerns. One of the most common side effects of chemotherapy is peripheral neuropathy, which can manifest as pain, tingling, burning or numbness in the hands and feet. This would contraindicate the use of any pressure, especially focused, "pointy" pressure on those regions, although gentle, broader, whole-hand contact may feel good. Massage therapists are advised to gather information about a client's neuropathy and response to touch, since these can be very individual and differ from client to client. There are anecdotal reports of clients responding well to touch techniques, relieving neuropathic pain.
Finally, muscle tension is common with chemotherapy and with any treatment that causes fatigue or pain. People in chemotherapy may sleep erratically, and may nap in uncomfortable positions, such as on couches or in waiting rooms. These produce characteristic tension patterns in the neck, shoulders and back. In this scenario, a therapist's clinical skills shine.
Therapists, familiar with bolstering, can help clients make simple adjustments in a pillow to alleviate muscle pain, or give tips for making the couch more comfortable. Moreover, massage therapists can alleviate muscle tension in these areas once all other safe practice requirements have been satisfied.