Originally published in Massage Bodywork magazine, June/July 2005.
Copyright 2005. Associated Bodywork and Massage Professionals. All rights reserved.
Once on a flight to San Francisco, I sat next to a woman who revealed she had received chemotherapy for cancer. The clinic where she had received treatment had a massage therapist who rubbed patients' feet as they received their IV medications. My seat mate raved about how glorious it was. I asked if she could describe why the foot massage was so wonderful. It was difficult for her to put into words except to say, "It restored my confidence in the goodness of humankind."
This is by no means a unique story. I have heard variations of it many times over. Massage gently coaxed Paul back to life after months of treatment for tonsil cancer. For Christa, it was a ray of light in an otherwise dark world. "It made life worth living," she once commented. Lois felt whole again despite never being cured of the disease.
I have also heard stories from cancer patients that disturbed or saddened me. Sue encountered a bodyworker who mistakenly thought a deep massage following four rounds of chemotherapy would help to eliminate the accumulation of toxins. Instead, it sent Sue to bed for three days with flu-like symptoms. It was six months before she dared try another massage. Following treatment for breast cancer, Sonia returned to her weekly massage sessions. After the first massage, she developed lymphedema from the use of overly vigorous pressure on the quadrant of the body in which lymph nodes had been removed. Ralph sought out non-painful, comforting massage after undergoing surgery for prostate cancer. He knew his body had been traumatized by the medical procedure, and he wanted to resensitize it. Instead, the practitioner was overzealous. The first time she put her hands on him, the discomfort was so intense, Ralph almost punched her.
Many therapists, because of a lack of clinical training, are working with cancer clients using primarily their intuition for guidance and hoping for the best. As these examples show, sometimes the outcome is absolutely sublime and at other times massage causes highly unfavorable results. No longer is it necessary, however, to guess or just intuit how to work with this population. For 15 years, massage has been making slow but steady progress as a complementary therapy in hospitals, hospices, cancer wellness centers, and chemotherapy and radiation oncology clinics. Large, well-established institutions such as Memorial Sloan Kettering, Dartmouth Hitchcock Medical Center, Massachusetts General Hospital, and Stanford Hospital and Clinics provide a variety of bodywork services for their oncology patients. So, too, do small, lesser-known hospitals in cities such as Toledo, Ohio; The Dalles, Ore.; Anchorage, Alaska; Mesa, Ariz.; and Boulder, Colo. Thanks to these and many other pioneering programs, there is now a large body of collective experience and wisdom that can teach us how to administer massage in the oncology setting.
In order to massage cancer patients, advanced training is often thought to be needed. I believe the opposite to be true -- the ability to work with this population should be part of a basic curriculum and should be taught to all therapists who use manual interventions. The rate of occurrence is so high, approximately 40 percent in the United States, that all bodyworkers will eventually come into contact with people who are in treatment for cancer or who have a history of it. Therefore, it seems logical that all touch therapists should have a fundamental understanding of how to administer bodywork to cancer patients.
The Real Issues
The fear that touch modalities will cause metastasis is no longer an issue in the oncology community, even if the bodywork has a circulatory or mechanical aspect. Science now understands this disease spreads due to genetic mutation, not because of mechanical forces such as massage or exercise. This does not mean there are no cautions to be observed when working with those in or recovering from cancer treatment. Therapists must be alert to the many side effects caused by chemotherapy, radiation, and surgery. When performing body-centered therapies with an oncology client, practitioners must make adjustments in three main categories:
- The level of demand (both physical and psychological) on the client.
- Avoidance of certain sites on the body.
The last two categories -- site restrictions and positioning -- can, with common sense, usually be figured out by the practitioner. However, bodyworkers often need guidance when learning to create treatment plans that are less demanding on the client. Hence, this is my focus here: Decreasing the level of physical and psychological demand on the person who has a history of cancer treatment.
The general principles I will present are applicable to the work of touch practitioners, movement specialists, and conditioning experts. The guidelines are the same whether the modality is Swedish massage, yoga, or weight lifting. Obviously, because my own focus is massage, the examples given throughout are a reflection of my experience.
Why Be Less Demanding?
First, it is important to clearly define what is meant by the term "massage." Often, it is thought of as soft tissue manipulation. But, when this is the reference point, the list of contraindications can become lengthy for those with cancer or other medical conditions. For our purposes, massage is defined as any form of systematic touch, which opens the possibilities greatly. Within this definition, nearly all clients, despite their infirmity, qualify for touch therapies of some sort.*
During cancer treatment and the recovery period, which may be a year or more, the body needs all its resources to heal, instead of coping with unnecessary stressors, such as vigorous exercise or deep massage. In most cases, it is not the disease that saps or damages the body, it is the side effects of chemotherapy, radiation, and/or surgery. Blood counts, immune function, lymphatic drainage, digestion, and organ vitality are all affected and take time to improve. Forceful massage is not helpful during healing because it stimulates the sympathetic nervous system, causing the heart rate to accelerate, blood vessels to constrict, blood pressure to elevate, and the gastrointestinal system to become depressed. These physiological activities, which are associated with the "fight or flight" response, are also a reaction to constant anxiety like that which accompanies the cancer experience. The person affected by cancer treatment, therefore, needs the restorative action of the parasympathetic response, which slows heart rate, dilates blood vessels, and increases intestinal peristalsis and gland activity. Long, slow, undemanding strokes such as effleurage initiate these rejuvenating, parasympathetic reactions.
There is no physiological evidence as to the demand massage places on the body of someone who has undergone cancer treatment. We must, therefore, rely on anecdotal evidence. Having worked with well over a thousand cancer patients and another thousand massage students and practitioners, I have a wealth of examples that offer proof for the need to be undemanding when working with this population.
For example, one of my hospital massage students once massaged a 31-year-old man who was being prepared for a bone marrow transplant. Willie was very fit and his blood counts were all good; his nurse gave the green light for whatever the patient wanted in terms of pressure or length of session. Even though the massage student tempered the pressure and despite the fact that the massage strokes felt comfortable to Willie at the time, he woke later that night in significant pain, which he attributed to the massage. From that point on, Willie was wary of massage and never again accepted our offer of a session during his hospital stay.
Another client who came for massage during chemotherapy always felt flu-like symptoms following his sessions. It wasn't until he had received several massages that he and the therapist realized the nauseous sensations were a direct side effect of the bodywork session. A third patient, someone who had recently been admitted to hospice, requested deep bodywork from the massage therapist. The practitioner sensed this woman was not a candidate for vigorous bodywork and was, with some effort, able to convince the patient that light acupressure would be more appropriate. As in the first example, the bodywork felt good to the patient in the moment, but later the woman admitted it was too much and had caused her discomfort.
These occurrences are not isolated examples, and they usually happen despite therapists' best efforts to not tax the client. In the above examples, each of the practitioners are people I personally know and highly capable, caring persons. Each of them was distraught to later discover the bodywork session had caused their client discomfort. I know each was operating from a place of high intention. But, despite those best intentions, the massage caused some physical suffering. The experiences of these clients and therapists, however, are extremely helpful to the rest of us; we learn through their mistakes. It is this 15-year accumulation of successes and failures that instructs us all in how to more safely perform massage for cancer patients.
- Bone fragility (either due to osteoporosis or bone metastases)
- Easy bruising
- Implications of pain medication
- IV catheter sites
- Sensitive or fragile skin
When we study the lengthy list of side effects caused by cancer treatments, it becomes very clear why bodywork, or other physical interventions, should be done in a gentle and measured way. Chemo-therapy, for instance, commonly results in a litany of consequences, (see "Chemotherapy Side Effects"), each of which requires the therapist to be more tender in her approach and less demanding.
Radiation invariably brings about fatigue and damage to the skin in the field of treatment. It can also cause many long-term side effects, such as constriction of soft tissues in the area that was treated. Bones in the field of treatment can lose their integrity, becoming fragile. When major organs, such as the heart and lungs, are part of the treated area, scarring can diminish their functioning. And, if the neck, axilla, or groin are part of the irradiated area, lymphatic functioning can be severely damaged due to scarring and adhesions in the nodal clusters. Each of these symptoms calls for the therapist to be less demanding.
Surgery, the third main type of cancer treatment, also requires the touch practitioner to be more cautious. Patients who have had surgery that involves a large amount of blood, such as an abdominal or thoracic surgery, are at some risk for blood clots. Cancer patients often have lymph nodes removed either to excise the cancer or as part of the diagnostic process. Lymph node removal, particularly from the neck, axilla, or groin, puts the person at risk for lymphedema for the remainder of her life. Fatigue is also a side effect of surgery that requires the therapist use a gentle approach. And, during this time, the patient needs to be "pieced back together" rather than enduring another invasive intervention.
Many of the consequences of cancer treatment, such as fatigue, nausea, easy bruising, incisions, or hair loss, are visible to both the patient and practitioner. Underlying these visible side effects, however, are assaults to the body that cannot be seen. Chief among these are the demands chemotherapy and radiation place on the body's major organs, especially the heart, lungs, kidneys, liver, and gastrointestinal system, thereby decreasing the body's ability to function at peak efficiency. Permanent damage can even occur. Lois, for instance, underwent radiation for Hodgkins disease. Included in the field of treatment were her heart, lungs, and spine. As a result, Lois was left with congestive heart failure, scarred lungs, and kyphosis, all of which required adjustments to her massage sessions.
The organs of detoxification, including the lymphatic system, become overextended as the body metabolizes not only the drugs but the debris from dying cancer cells and other cells affected by the treatments. This cellular debris overloads lymph nodes that are part of the body's filtration system. Additionally, during treatment, patients are more sedentary. Muscular action is one of the prime movers of the lymphatic system, and the lack of it causes lymph to stagnate, much like sediment in a pond. A demanding massage can then stir up this sediment, overwhelming the lymphatic system's filtration capability. Readers may have had the experience of feeling unwell following practice sessions when taking a lymphatic massage class. Imagine then the response of a body that has undergone cancer treatment. It, therefore, makes sense to spare the body from stirring up the waste products, which then spares the client from experiencing flu-like symptoms for days following the massage. A focus on being supportive and nurturing creates many beneficial outcomes -- physical energy increases, people feel whole and lovable, and pain and anxiety lessen, just to name a few.
Equally important as the physical side effects are the psychological repercussions. Perhaps more than any other group of practitioners, touch therapists understand the connection between psyche and soma -- that which assaults the body, also assaults the emotions.
In case you are not familiar with what cancer patients go through, let me help you imagine some of their treatments. Imagine being left alone in a lead-lined room, lying on a stainless steel table while the technicians operate the machinery positioned over your head with remote controls because it is too dangerous for them to be in the room. Imagine repeating this every day for 35 days. Try to envision IVs being placed in your arm each time you are given chemotherapy. See yourself having radioactive dye injected into your veins or your neck being awkwardly positioned for 40 minutes while a diagnostic scan is performed. Imagine your head is locked in a mask that ensures there will be no movement while radiation is beamed into your brain, or that your jaw was removed because of tongue cancer, or that your bowels empty into a bag attached to the outside of your body, or that your hair has fallen out. It is no wonder people with cancer sometimes develop posttraumatic stress disorder because of the invasiveness of the treatments.
The healthcare providers who must deliver these treatments do their best to be sensitive, but there is an inherent intrusiveness that affects most patients. Touch therapy is one of the best ways to heal the insults to the body, mind, and spirit. In order to accomplish this, practitioners must be willing to set aside their agenda, to move slower and more gently into the relationship with an emphasis on building trust. Like someone who has suffered a physical trauma, cancer patients may be disconnected from their body or the part of the body that has been treated. They may be unaware of how their body feels, including pain levels or areas of holding and therefore unable to give the massage therapist accurate feedback. And so, the patient's body must be touched with hands of peace, whispered to instead of shouted at, reverently anointed, or handled as if it is a delicate flower.
How to Be Less Demanding
When receiving touch therapy, cancer patients require individual adjustments, with modifications that might change from week to week. For instance, when I worked with Alan during his radiation treatment, he was fatigued and depressed. The two adjustments I consistently made were a decrease in pressure and slowing the speed of the strokes. One week near the end of his radiation, Alan was so deeply distraught, he could barely relax enough to lie down. That session ended abruptly as Alan bolted off the table, unable to lie still for a moment longer.
There are many types of adjustments that can be made so the bodywork session is less demanding on the client. Generally, not all of the following variables need to be changed for each client.
- Changing modalities.
- Decreasing the duration of the sessions.
- Decreasing the pressure.
- Giving the sessions at the client's home.
- Handling the body with great mindfulness.
- Letting go of the intention to "fix" the client in favor of just "being."
- Slowing the speed of the strokes.
The majority of oncology patients who are in treatment always require less pressure and slower speed of strokes. By doing this, it is possible to administer nearly any touch technique, even those normally thought of as vigorous, such as Thai massage or trigger point therapies. Most people also need us to handle the body with exquisite mindfulness. And even then, cancer clients are brought to tears as the trauma dissipates from their bodies. Lois always cried at the beginning as my hands lightly cradled her face. With Betsy, who had finished treatment for breast cancer a month earlier, just placing my hands mindfully onto the treated arm brought a big breath. When I asked her about it, she quietly started to cry and said, "When you touch me, I'm afraid. I've been handled so roughly throughout my treatment."
One of the best ways for therapists to lessen the demand is to let go of any intention to fix the person beneath their hands. When practitioners want to "fix," that expectation places a demand on the client, a goal that implies success or failure. And, as author Rachel Naomi Remen points out, "There is distance between ourselves and whatever or whomever we are fixing. Fixing is a form of judgment."
To be present with people is enough -- to embrace their bodies and psyches just as they are. People change when they are received in this way.
Gauging the Level of Demand
Gauging the level of demand of massage on a cancer client's body is difficult for both the client and the therapist. Patients who have received massage prior to being diagnosed with and treated for cancer mistakenly believe they can tolerate the same type of bodywork sessions as before. In my experience, that is never the case -- ever. Even the most robust of clients find they must modify their activities as they are going through treatment and recovery. The most common adjustment to the massage session will be the use of a soothing, nurturing pressure rather than a deep or vigorous one.
I teach therapists to "inch forward" with the level of demand. Begin the first session with the idea of creating a baseline. Engage in superficial contact focusing on no more than the surface layer of muscles. If the person is fragile, use a level of touch that focuses only on the skin. For the first session after the start of treatment, even if you have worked with this client for years, perform the entire massage at an undemanding level, resisting the client's urging for deeper pressure or your own need to do more. Concentrate on restfulness, tranquility, and ease. There should be no attempt to dig deep or fix musculoskeletal problems. Interestingly, even when the massage is gentle, with no specific agenda, amazing clinical outcomes occur. The research is fairly clear about the effect of massage on pain, anxiety, and nausea. Each of those three variables shows significant improvement immediately following touch sessions. Anecdotal evidence also suggests that systematic touch can help some people sleep better, temporarily decrease fevers, improve bowel function, and decrease fatigue. Deep, effortful bodywork is not necessary to achieve profound results.
Massage schools train therapists to ask clients if the pressure they are using is comfortable. While this is a necessary question, it is not an adequate measurement for the therapist working with cancer patients.
The feedback a cancer client gives in the moment is not always an indication of what is appropriate. Time and again I have listened to clients' stories of how wonderful a massage felt while they were receiving it, only to be in pain or have flu-like symptoms that evening or the next morning. Granted, this discomfort is temporary and causes no long-term damage, but it can create an aversion to massage, such as occurred with Willie, mentioned earlier. Lymphedema, however, is the exception to this rule of "it's only temporary." When lymphedema is triggered, which can happen because of massage, it can cause long-term side effects. (For more detailed information on the adjustments needed for those at risk for lymphedema, see "Cancer, Radiation, and Massage," August/September 2001, page 16, and "Edema
and Lymphedema," December/January 2005, page 46, or visit the archives at www.massageandbody work.com.)
What clients report in the moment may not be an indication of how they will feel in six hours. The therapist must use other guideposts in order to gauge the appropriate level of demand, such as:
- Other demands on the body. The body may already be overtaxed from other interventions and activities. For instance, perhaps the client is zealously trying to regain her health and has increased her level of exercise, is receiving acupuncture, and is taking supplements prescribed by a naturopath to cleanse the liver. Heavy, or even moderate, massage would be ill-advised during this time.
- Exercise level. This can tell a practitioner a great deal about how much the body can tolerate. However, do not assume that if the client is able to walk several miles or that she is back in the gym, it means the massage does not need to be moderated. It still needs to be given in a restrained manner. Remember, inch forward.
- Length of time in treatment. The person who has had cancer treatment for years will be less able to tolerate a robust massage.
- Looks can be deceiving. The practitioner must bear in mind the treatments that affect unseen parts of the body. Appearance cannot be used as a guideline because often patients appear amazingly healthy.
Therapists often ask, "What if clients request or even demand deep massage?" This can almost always be avoided by explaining to clients prior to the first massage that their body has a "new normal" and that there is no way for them or the practitioner to know what that "new normal" is. Together, you must slowly and cautiously discover what the body and psyche can tolerate. I explain to the client that we are going to gradually work up to deeper pressure. I tell them that within 48 hours of each session I will call to see how they felt after the massage. And, if there was no deleterious outcomes, we will inch forward the next time. When clients know that they eventually will be able to have pressure that is firmer, they are very agreeable to this systematic plan.
Practitioners must take a stronger leadership role in guiding the massage sessions. Clients, and even their healthcare providers, don't usually understand the effect of massage on the body. Rather than caving into what the client wants in the moment, the bodyworker must educate the patient before the session begins and explain the principle of inching forward.
Patients who have leanings toward complementary modalities may request the massage therapist assist them in detoxification of the body. Helping a client detoxify following cancer treatment is an appropriate goal, but it should come after other things have been accomplished. Confidence in the body must be regained, the trauma of undergoing medical treatment dissipated, and wholeness reestablished. The "new normal" must be discovered. All of this may take months or more. Detoxification regimens place demand on the entire body, a body that is still processing the consequences of chemotherapy, radiation, or surgery. Wait until the client is well-recovered from the obvious side effects of treatment, such as fatigue and immunosuppression, and is no longer on a long list of medications.
In massage school, I often left pathology classes more afraid than before I went in. I hope that's not how I've left you here. Awareness, precaution, and care are the things I hope you can take away from this -- not fear.
Even after I was a licensed massage therapist, I nearly gave up the profession after hearing a petrifying lecture on deep vein thrombosis. It is not my intention to be frightening here. So, in case I have recounted too many stories that were focused on the potential for injury or suffering, let me end by reiterating that nearly all cancer patients can safely receive massage if certain adjustments are made, such as decreasing the level of demand on the client.
Massage, given with care, has the capacity to open hearts, create wholeness, and change lives. Erna is an example of this. I never tire of hearing her story of how doctors cured the cancer, but massage helped her "connect with healing." That's important work.
Gayle MacDonald is the author of Medicine Hands: Massage Therapy for People with Cancer (Findhorn Press, 1999) and Massage for the Hospital Patient and Medically Frail Client (Lippincott Williams Wilkins, 2005). Readers can reach her at firstname.lastname@example.org. MacDonald's teaching schedule can be found at www.medicinehands.com.
*Please note that for the sake of variety, the words "touch" and "bodywork" are used synonymously with "massage." "Client" and "patient" are used interchangeably, as are "therapist," "practitioner," and "bodyworker."