It’s cold out, and your client keeps her socks on during her massage, leaving them for you to remove when you’re ready to work on her feet. As you peel off her left sock, you notice an abrasion on the ball of her foot, one she hadn’t noticed because of her loss of sensation.
Later, feeling inside her shoe, you both notice the corresponding fold in the leather. Because of her diabetic neuropathy, she never noticed it, and it has worn away at the skin on her foot.
Another client with HIV and neuropathy complains of burning pain in his feet that make it difficult to walk. He struggles to get to your office and heaves himself on your table, glad for some attention to his feet.
Yet another client is struggling with tingling and numbness in her hands and feet. She is in chemotherapy, and praying the neuropathy will go away once cancer treatment has ended.
How neuropathy affects people
Peripheral neuropathy disrupts the function of one or more peripheral nerves, causing changes in sensation or motor function. The term typically describes a disease or injury of one or more spinal nerves serving the hands, feet, or both. It can also affect the special senses or internal organs.
Often termed “neuropathy” for short, the condition is usually a complication of another condition such as diabetes or HIV infection. It can be a complication of chemotherapy (chemotherapy-induced peripheral neuropathy or CIPN), B12 deficiency, excessive alcohol use, toxic exposure, or inflammatory conditions such as autoimmune disease.
Symptoms often occur in the hands and feet, and range from a mild “pins-and-needles” sensation (parasthesia) or slight pain on up to debilitating pain. The pain often has a burning quality, and is worse at night. People with neuropathic sensation loss often describe it as having thin gloves or socks on that interfere with sensation. Motor weakness can also occur.
To work well with neuropathy in the extremities, there are 5 questions to ask and 2 principles to practice. Italics below describe how to link your client’s answers to your massage precautions.
1. Where do you experience the neuropathy?
This is an area for cautious with pressure and joint movement. Whether the client’s neuropathy plays out as pain, impaired sensation, or impaired movement, be very gentle. Joint movement should be minimal. Typically the pressure used to apply lotion, “light lotioning,” is the maximum used, with good firm contact.
Even if a client with impaired sensation argues for deeper work, stick to gentle pressure. The client may not be able to feel the pain that signals tissue damage, and pressure should be cautious.
If you do increase your pressure, do so in tiny increments over many sessions, to learn the right pressure for the client.* Make sure you are following pressure guidelines for related conditions. Also, if the feet are affected, balance may be affected. Be watchful.
2. How does it affect you? How is it affecting you today?
Symptoms of neuropathy call for gentler pressure and joint movement, as noted above. This is typically true no matter which symptoms are present: numbness, pain, or burning. If motor problems are present, caution is still advised.
3. What is the cause?
Always adapt massage to the cause of the neuropathy as well as the neuropathy itself. Depending on the client’s presentation, massage modifications will be in force for most causes of neuropathy, such as advanced diabetes, chemotherapy treatment, and HIV disease. These guidelines are too lengthy to go into here, but you can find them in my textbook, Medical Conditions and Massage Therapy: A Decision Tree Approach or another massage and pathology text.
4. What is the condition of your skin in the area?
Ask this question out loud, but also inspect the tissues each time you begin contact with the area. This is especially true of the feet. As in the story above, friction from a foreign body in the shoe, ill-fitting socks, and other irritants can go unnoticed. You’ll want to bring it to the client’s attention, for sure.
To avoid causing infection, you will also want to avoid contact with broken skin, and avoid introducing lubricant into an opening.
5. How is it treated? How does treatment affect you?
Drugs for neuropathy include low-dose antiseizure medications, pain relievers, and even tricyclic antidepressants. Usually side effects are mild, but it’s important to ask about them. Adapt massage to any side effects, which may include drowsiness, dizziness, and nausea.
These 5 questions are essential for working safely with clients with neuropathy. Questions 1 and 4 highlight our approach to massage when there is sensation loss. Because it’s easier to remember a handful of massage principles than a few hundred conditions, I offer a couple of principles here.
The Sensation Principle
The Sensation Principle is practiced by massage therapists across many nervous system conditions. The principle states, simply, “In an area of impaired or absent sensation, use caution with pressure and joint movement.”
Massage therapists follow this whenever sensation is compromised, whether from peripheral or central nervous system disease or injury.
The Sensation Loss, Injury Prone Principle
Another time-saving principle for nervous system conditions is applied when sensation is impaired or absent. The Sensation Loss, Injury Prone Principle states “If a client has lost sensation in an area, inspect the tissues carefully for injury before beginning the massage.” This principle captures our concern about open skin, identifying it early in the massage, and bringing it to the client’s attention.
With the right questions and thought, massage can be easily adapted to peripheral neuropathy. Remember that neuropathy is often a complication of another condition such as HIV, diabetes, or chemotherapy treatment for cancer. With additional massage guidelines in mind for related conditions, massage may provide real support for a client who is living with neuropathy.
* Pittsburgh-based MT Valerie Vogel tells wonderful success stories of massage for neuropathy. See Medical Conditions and Massage Therapy: A Decision Tree Approach, page 169-172, for a neuropathy decision tree and Valerie’s work with clients with HIV and neuropathy.
Thanks Tracy for the insightful, thoughtful discussion. I have forwarded it on to my colleagues.
Very helpful article.
Thank you Tracy!
I once helped another MT who had Peripheral Neuropathy.
We worked together for about a year on her feet (I say “together” as there was a lot of Q & Feedback), and she started to get feeling back! The light, cautious, work to her toes and feet really helped,
plus it gave her an opportunity for someone to really take a good look at the bottom of her feet for signs of injury (which she very rarely was aware of).
Thank you for this wonderful article. May it help many maintain feeling, and or regain feeling!
Pam, so interesting that light touch helped, especially given Wendy’s comment below and Valerie’s story in my book! Thanks for the input. Maintain and regain!
Terrific Tracy, thank you so much….so helpful….
Thank you, Tracy
Hi Tracy,
I enjoyed taking your course in outpatient oncology massage several years ago at the Florida School of Massage. I appreciate you writing this article because I think it’s such an important topic for those massaging cancer patients (or any other PN sufferers) to be cognizant of. After I took your course I took the Clinical Oncology Massage course at WIlliam Beaumont Hospital in Royal Oak, Michigan. They have developed their own protocol specifically for treating CIPN of the hands and feet. That protocol includes intentionally using deep pressure for the purpose of compressing the effected tissues against the bone. The rationale is that this will stimulate increased blood flow to the nerve endings, aiding them in regeneration. Or at least this is how I understood it. I believe they were conducting research on this topic recently but have not yet seen the results of that study. I’d be very curious to find out!
After training at Beaumont Hospital I went on to work in an outpatient cancer center using this protocol on patients with CIPN during their infusions for two years. None of the patients I worked on had any issues with skin integrity of the hands and feet, which I feel is an obvious contraindication. Anecdotally I can say that this Beaumont protocol was extremely effective and brought many of my patients a lot of relief, including in cases where the CIPN would have been a dose limiting side effect and effected treatment outcomes.
I was wondering if you were aware of this protocol or not, and your thoughts? Judging by the things you stated above I’m assuming you would feel this type of pressure is not appropriate?
I’m currently in an undergrad program for nursing. I’m very interested to do my own research with regard to the efficacy of this particular protocol when I enter my master’s program- or even sooner if I have the opportunity. I’m looking forward to blending my homeopathic and allopathic knowledge to hopefully give the cancer patients I care for the most holistic and effective care possible.
Thanks for all the good work that you do, it is much needed and appreciated!
Wendy L. Froman, LMT, SN
Wendy, I remember you! Good on you for going to nursing school! I AM familiar with the Beaumont protocol. I know they are doing some research, I interviewed Karen Armstrong for the last webinar series on hospital-based massage. I hear lots of reports of effectiveness of deeper work (one story in my book by Valerie Vogel, above), and I definitely respect the potential benefits. BUT I don’t think it should be attempted by the uninitiated, and increases in pressure should be gradual over a course of therapy so as not to overtreat. Thank you for raising this. We need to learn more about massage, pressure, and CIPN. Hopng you’ll be at the forefront of all of this. Keep in touch!
Sheila, Cheryl, Kristen, David: Thank you for taking the time to comment…:)
Thank you for sharing this. I feel a bit more confident with the decisions I have made and continue to make. Education is such a vital piece working with those experiencing PN. Even some of the health care providers I see as clients will debate the pressure levels, but feeling validated is purposeful. Thanks Tracy!
Hi there, Jessi: the debate is a good thing, right? So is any conversation at all. Glad we are all talking about it. 🙂
When taking chemotherapy it is good to get massage and neuropathy treatment.
Sorry, I’m not sure what the question is?
Hi Tracy,
When should one start on the massage? If a patient is on a chemo every 2 weeks, should massage be done during week 2 to help with some recovery of neuropathy, but to stop during week 1 (Days 1-5, for example) because that is when the chemicals are at its highest in the body?
I was wondering if starting massage now would be better than waiting for the whole course of chemo treatment is done, which is a few months away.
Any help is much appreciated.
Rhonda, this is a great question. There are lots of factors to take into account when working with someone in chemotherapy, and timing is one of them. We would work differently during the first few days than the last week of a cycle, but not necessarily withhold massage entirely. I recommend Gayle MacDonald’s book, Medicine Hands: Massage Therapy for People with Cancer for more specific guidelines about chemo, including timing and the concerns you raise about chemotherapy reagents. Be sure you get the 3rd edition–it’s got the most updated conversation on this topic. I hope that helps!
Hi there, Rhonda: Not sure how I missed your comment, apologies! Your question is a good one. It depends on so many factors–the medications, the side effects, the activity and energy level, and so on. Certainly massage can be done during chemotherapy treatment with proper adaptations. I would turn to Gayle MacDonald’s 3rd edition of Medicine Hands for specific guidelines.
Thank you for an excellent article. I would like to say that I find our wholesale acceptance of pharmaceutical drugs as “treatment” quite disturbing. You say that “Drugs for neuropathy include low-dose antiseizure medications, pain relievers, and even tricyclic antidepressants. Usually side effects are mild, but it’s important to ask about them.” These are very serious drugs that have devastating, life-changing side effects and I think it would be helpful if we give voice to all the people who are suffering those side effects. I’m often shocked at how we have come to accept drugs as appropriate treatment for almost everything even though we know for a fact that drugs treat symptoms and also create new symptoms over time. All that being said, it is an excellent article and I appreciate you taking the time to share your knowledge, experience and understanding.
Thanks for the feedback, Zoe! I do think the lower doses mitigate some side effects in the neuropathy drugs, but we all want more options for treatment, right? I hope we all keep an eye on the research for good alternatives in the (hopefully) near future.
I have atypical facial neuropathy and have started to have massages on my face. Where some of my numbness has been along my jawline, this has started to resolve. It’s such a wonderful feeling to be able to smile again without pain. Such a blessing. Wonderful to know the physiological background of massage and neuropathy. Thank you.
Lauren, what great surprise and wonderful news! Thanks for sharing it!
Thankyou Tracy for sharing about Neuropathy. I have a client for 12 years with neuropathy in his feet. I massage him every week. He’s not a diabetic either! He tells me his much his feet feel better after the massage
Melissa, this is a good story. I’m glad massage seems to be helping.
Great blog on neuropathy Tracy! I had one client who had it on his feet. He got weekly massages for years. He said it helped him alot! THANKYOU for sharing this ! ❤