Two clients come in with interesting stories. The first tells you she received chemotherapy two days ago while wearing an odd-looking cap with a chin strap. It was a special “cold cap” cooled her scalp during the chemotherapy infusion. It made for a chilly session, so the infusion staff took pains to keep the rest of her body warm during the infusion.
The second client tells you about wearing frozen gloves and socks throughout his infusion, also a couple of days go. He didn’t find it comfortable, either, and the staff took extra measures to keep him warm.
As uncomfortable as it seems to add these accessories to the treatment, there were good reasons to cool the scalp, hands and feet in these clients.
Meet the Latest Tool in the Cancer Care Toolbox
A new strategy—cold therapy—is being used on the scalp, hands, and feet to diminish the effects of certain chemotherapy drugs. Massage therapists have questions about how to modify massage therapy for clients using this strategy. The purpose of this post is to answer those questions.
To back up: Most chemotherapy is delivered by infusion directly into the bloodstream. From there, it is distributed throughout the body. Delivery through the bloodstream means that the drug goes to nearly every tissue, not just to the tumor. Delivery through the bloodstream also means that side effects are systemic, rather than selective. In a sense, chemotherapy drugs cannot tell the difference between friend and foe, or the difference between healthy tissue and tumor.
Systemic side effects of chemotherapy, such as hair loss, chemo-induced peripheral neuropathy (CIPN), nausea, and fatigue are caused by this wide, nonselective distribution.
Some side effects of chemotherapy are distressing and uncomfortable, but others can be devastating. Some, like hair loss, are short-term effects. Others, like neuropathy, can last for years or even indefinitely, causing pain and debilitation long after cancer treatment is over.
Freezing out the Medicine
Local cold applications are used to steer chemotherapy away from certain areas by constricting the vessels in that area, minimizing blood flow through them. It doesn’t stop flow entirely (and you wouldn’t want it to. Hypothermia! Tissue damage!), but it narrows the vascular plumbing in the protected area. The goal is to reduce the exposure of local tissues to the drug. To protect the scalp, a cold cap on the head is designed to ease hair loss. To protect the hands and feet, frozen gloves and socks are designed to reduce the amount of drug flowing through their vessels, limiting the injury to local peripheral nerves.
These local cold applications take the form of caps, gloves, and socks. Here are some examples:
“Cold caps” and scalp cooling systems are used immediately before, during, and just after some chemotherapy sessions to diminish hair loss. Cold caps such as Penguin and ElastoGel work similarly to ice packs, and are replaced as they thaw. Scalp cooling has been used in Europe for decades, but is fairly new in the US. Cooling systems made by Paxman or Dignitana offer continuous coolant circulating through the cap. DigniCaps have been approved by the FDA for use in the US since 2015. (Click here for a picture.)
Cold gloves and socks are being applied to lessen chemo-induced peripheral neuropathy. In one study by Hanai et al, reported very recently in the Journal of the National Cancer Institute, participants received cold therapy on one hand and foot, and no cold therapy on the other side. Thus, they served as their own control in the study. Investigators found significant differences in the two sides in subjective experiences of neuropathy symptoms as well as objective performance in manual dexterity tests.
For massage therapists working with clients before, during, or after chemotherapy infusion, how do these new technologies affect your approach? Should you massage the hands or feet? The head? If not now, when?
How to Adapt Massage Therapy to the Scalp?
It’s easy to modify massage for a client receiving scalp cooling therapy. A person attempting to preserve their hair through cryotherapy is not going to want their hair pulled or dragged in any way. They are instructed to brush gently to hang on to as much hair as possible. Massage should honor this goal, throughout treatment, as long as it is vulnerable.
If a client wants touch on the head, we keep it to stationary holding rather than any friction that would pull on the hair. This avoids pulling, and avoids any strokes thought to be circulatory. While we’re at it, avoid getting lotion or oil on the head, if the client prefers.
How to Adapt Massage Therapy to the Hands and Feet?
The key here is also to align with the goals of the health care team. The purpose of cold therapy is to reduce blood circulation to an area. Classical massage strokes—notably effleurage, petrissage, friction, repeated compressions—are thought to increase blood circulation in superficial tissues in the areas worked. As massage therapists whose work is circulatory in intent, we need to work with the purpose of the cryotherapy in mind.
Here is where crystal clear guidelines get fuzzy. How do we avoid raising circulation to the hands and feet?*
- You can avoid raising redness, but unfortunately visible hyperemia is only visible after you’ve already raised superficial circulation. So redness is only a reliable indicator of failure to stay within the lines, not of success.
- We can avoid the strokes listed above, but then we get into an argument about which pressures make those strokes circulatory. Is it pressure level 3 on this scale? Pressure level 2?
The safest approach would be to avoid contact with the hands and feet altogether. Maybe light holding of each, but only brief. You don’t want to warm the hands or feet if they are supposed to be staying cool.
This guideline is in place just before, during, and just after the infusion. It continues until the drug has been fully eliminated from the body.
How Long is That?
Recall that your client has come to you a two days after the infusion. The cold therapy was applied during the chemotherapy infusion, and for 15-60 minutes beforehand and afterward.
For patients using cold therapy on hands and feet, we avoid circulatory work on the hands and feet as long as the drug is thought to be present in circulation.
Turns out, this length of time can be difficult to determine. The time it takes to completely eliminate a drug from the body is dependent upon the drug, dose, size of the patient, health of the patient’s kidneys and liver, and other factors. The best source of information about a given situation is the hospital pharmacist, but most MTs do not work down the hall from the pharmacist to ask this question.
The Dana-Farber Cancer Institute blog gives a general idea, though. They say that most chemotherapy drugs remain in the body for a matter of hours or a few days. So avoiding circulatory intent at the hands and feet is a good guideline for several days following the infusion.
Massage in the Infusion Room, during Chemotherapy?
Common sense can answer this question: Not on the areas that are cooling. The cap/gloves/socks are in the way! They present a physical obstacle to massage, and a mental reminder of the areas to be careful with afterward.
How about Other Patients at Risk of Neuropathy?
So let’s extend this discussion. Suppose your client has just had chemotherapy with a risk of CIPN, but did not receive cold therapy? What does this mean for the client? Should the client receive hand and foot massage just before, during, or in the hours/days after infusion?
This is a larger question, and one that the oncology massage therapy field should discuss. In the safest approach, we would follow the same guidelines and avoid raising circulation for these clients, as well. We would take care during the hours and perhaps several days after an infusion.
Yet many massage therapists suggest that foot or hand massage can ease neuropathy, and there is at least one published case report of this finding. Given the considerations above, the timing of that hand/foot intervention seems important. I would not do it until several days have elapsed after chemotherapy.
These newer treatments require new discussions: Many MTs are providing hand and foot massage in infusion units. Together, we need to arrive at meaningful standards of practice for the timing of hand and foot massage for people at risk of CIPN.
What Else Do I Need to Know?
This post is devoted to just two issues: hair loss and CIPN. But there are other side effects of chemotherapy, and other guidelines in place for them. During chemotherapy, hands and feet may be at risk of skin breakdown from certain drugs. Nausea and fatigue require a careful approach. Low blood counts require thoughtful interview questions and massage modifications. Even a surgery history can require a complicated array of massage modifications, and massage must be adapted to signs and symptoms of cancer itself.
So it’s important to have training, or at least read the literature on oncology massage therapy before working with a client during chemotherapy. It turns out, there is a lot of literature, and one should be required of all therapists: the 3rd edition of Gayle MacDonald’s Medicine Hands: Massage Therapy for People with Cancer.
I did not start my career knowing what to do with this question. Cold treatment wasn’t a thing back then. But using a few principles, including aligning my goals with those of the health care team, and looking up some information, asking knowledgeable people, using the best sources in the field, we can adapt to new developments in cancer care.
With thought and care, we can work safely with people during treatment, even as treatments evolve.
Although a rise in blood flow is assumed to be an effect of Swedish massage techniques, the accuracy and significance of “circulatory massage” is a live question. For the purpose of this post, we’ll assume massage could raise circulation in superficial tissues of the hands and feet, at the site of massage. For more on this topic, see my free downloadable e-book, 5 Myths and Truths about Massage Therapy, below.
Hanai A, Ishiguro H, Sozu T, Tsuda M, Yano I, Nakagawa T, Imai S, Hamabe Y, Toi M, Arai H, Tsuboyama T; Effects of Cryotherapy on Objective and Subjective Symptoms of Paclitaxel-Induced Neuropathy: Prospective Self-Controlled Trial, JNCI: Journal of the National Cancer Institute, Volume 110, Issue 2, 1 February 2018, djx178.
MacDonald G. Medicine hands: massage therapy for people with cancer (3e). Forres, Scotland: Findhorn Press 2014.
Neighmond P. Cooling Cap May Limit Chemo Hair Loss In Women With Breast Cancer. National Public Radio, February 14, 2017.
Peachman RR. Scalp-Cooling Caps Help Prevent Hair Loss in Chemo. The New York Times, February 14, 2017.
Walton TW. 5 Myths and truths about massage therapy: Letting go without losing heart. Massage Therapy Foundation, 2015.