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.
*Note
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.
Resources
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.
Thanks for this great insight!
Dear Tracy, Just read info regarding chemo-cooling. I am an LMT who is currently in nursing school. What therapists need to know also regarding chemo drugs are what they do when they reduce blood cell counts and when these counts are lowest (the nadir). If they reduce thrombocytes, the pt is at risk for very easy bruising and bleeding. Decreased WBCs will increase risks of infection. These low points during chemo can take place even 10 – 15 or more days after a pt’s infusions. So much information for pt AND therapist to be aware of for safe treatments! P.S. – i will be coming to your June class.
Denise, you are absolutely right. I mention low blood counts at the end of this post, but there is not space to go into the detail as you mention–there is in deed a lot to be aware of and incorporate. We will cover it in the course and we look forward to meeting you. Congrats on nursing school AND LMT. We need you.
I have been a massage therapist and polarity practitioner for 35 years, working with many cancer patients for the past 16 years. It seems to me that cryotherapy is a defensive approach to controlling the side effects of chemotherapy and by its very nature rules out any massage benefits, massage being an active approach whose benefits are based on increasing and balancing the circulation of body fluids and energy in the whole system. It’s hard to prevent the effects of massage in one area of the body from reaching another part!
It seems to me that massage therapy techniques, even gentle ones applied to other parts of the body, would increase circulation in feet, hands and scalp regardless of cooling attempts. I certainly understand the wish to save oneself from a period of chemo hair loss and especially to prevent neuropathy in hands and feet which can be long-term or even permanent.
Based on my experience as my husband’s caregiver during his cancer journey in 2016, I believe activating the circulation could be the best way to go to prevent long-term neurological effects in hands and feet. I gave him a nightly foot massage and he slept with his lower legs and feet elevated during the 6 months of his chemotherapy. With each dose, he had some minor changes of sensation and tingling in his feet which did not persist after treatments were over. Maybe those
foot massages helped. Then again, maybe the elevation helped.
So I think I’m in the “boost the circulation” camp, unless I consider the possible benefits of the elevation that slowed the circulation for hours at night (much more comfortable than ice!) This is a very interesting topic and I’ll be thinking about it a lot more now and looking for more research to study. Thank you!
Thank you for sharing, Katherine. I appreciate interpreting the results of your own experience cautiously, and I think there is room for more research on cold therapy and massage and circulation. I’m not certain that massage in one part of the body produces systemic effects; even though it is a closed system, there is a lot of slack in it. So an increase somewhere can be limited in effects by autoregulation. We do know that metabolic demand, e.g. activity, is a true booster of circulation. I think we’ll know more about these other factors one day, hopefully soon. I am grateful for your thoughts and reflections.
Thank you Tracy for again bringing relevant and substantive issues up for discussion!
As an infusion center MT practitioner and teacher of Infusion Center courses, my first response was literally, head in hand, ”OH No… could I be doing harm?”
Mulling it over, re-reading the post and the research study re Cryotherapy, talking it out a bit with colleagues, and sleeping on it, here is my 2cents worth:
1) Do doctors advise chemo infusion Pts to NOT walk, exercise or use their hands before, during or after infusions? No, not that I am aware of
2) Could it be that gentle massage (with whatever limited impact on circulation that it has) actually reduces the risk of neuropathy?
a. Circulation is movement, not stagnation. Does the massage also move the chemical away from the periphery, thus potentially reducing CIPN?
b. Swelling/Edema have not been associated with massage indicating no additional pooling effect in the extremities
c. The protocols I use and teach have strokes toward the heart, and not pulling down to the toes, fingers. (Following lymphatic drainage type treatment)
d. Elevation that is used in foot massage and often somewhat in hand massage might be an additional treatment against CIPN which is a structural aspect of MT
3) Benefit/Risk ratio – I would be horrified to know that my MT contributed to someone’s risk for neuropathy but I am not convinced that this a likely conclusion, AND I think of the stacks of Pt evaluations I have universally reporting that the MT was of significant benefit. There are countless notes from grateful Pts expressing gratitude for the service that made the treatment more tolerable, less stressful, even a pleasant experience. Many Pts literally schedule their infusions based on our shifts.
My conclusion, until more research or further input is offered, is that gentle, appropriately adjusted (see above) massage is still indicated, just as exercise is not contraindicated; and that the stress reduction benefits are of significant value to the overall wellbeing and treatment tolerance levels.
I have shared these thoughts and suggestions/request for research with some of my UCSF Medical Center MD colleagues at the Osher Center for Integrative Medicine. I will keep you posted of their input as well.
Thanks again Tracy for bring these important topics forward and to all of the great practitioners out there, so grateful we are on this amazing team together. Looking forward to the conversation continuing…
Carolyn
Hi! My dad starts chemo on Tuesday and the nurse mentioned we should get him cold socks/gloves to help prevent CIPN… im having the hardest time understanding what gloves/socks we should get him…. google and amazon searches aren’t really helping. Do you have any suggestions about specific ones to try? Like – would these work? https://www.amazon.com/NatraCure-Therapy-Wrist-Elbow-FBA715/dp/B00IK032Q6/ref=cm_cr_arp_d_product_top?ie=UTF8&th=1; https://www.amazon.com/NatraCure-Cold-Therapy-Socks-treatment/dp/B003L4WOKG?ref=ast_p_pc_bs
Or do we just latex gloves?! Any help would be GREATLY appreciated.
I wish we could help, but it’s not in our scope. Please ask the nurse to guide you. Good luck!
Well I was looking for the same thing as Angela G- and good luck with “asking the nurse to guide you”. Because they do not have that information! As usual, it is up to the patient to figure it out. So that is why she and I and so many spend time looking around .
At our infusion clinic, we had a study with cold gloves and booties. One glove on one hand and one booty on the contra lateral foot. No benefit was found from using them. One patient confided to me that she actually felt the ice glove and boot sides were worse!
Cold therapy is not new in infusion. Long time oncology nurses (practicing since the 70s) I work with share that they believe they notice increased brain mets with cold caps on breast cancer patients. One questioned whether restricting drug flow is wise because reduced potency might be missing those stray cancer cells.
Lots more research needed.
At the one day joint integrative oncology, fascia, and acupuncture conference a few years back in Boston, I saw a poster presentation which I understood to be hypothesising fascial restriction was contributing to CIPN, and he found with plantar stretching, CIPN reduction. I have observed a case of inadvertent fascial stretching eliminating an early , but persistent, case of CIPN.
I’m not a big believer in the benefits of cold therapy for CIPN reduction, though I would be eager for my opinion to change . I’ve seen several mediocre cases of successful cold cap application, better results with thicker hair to begin with. If that is what people want, fantastic. Losing hair is hard for both men and women. And like you said, work around the caps. It’s not a big deal. The transitioning of caps is amazing to watch. It’s like a pit crew. Very cool. You might need to pause your treatment in that moment.
More research needed. And I always like your warnings to us to not overproclaim or falsely claim any benefits of massage therapy. Likewise, I’m hesitant to overproclaim the benefits of some other seemingly trendy and inconclusive research.
I’m my enthusiasm of sharing about CIPN and cryotherapy, I didn’t get to express how truly grateful I am for the work you are doing to advance the field of massage therapy. I am extremely grateful and promote the work you have done, especially about the things we were taught as canon which make no sense e.g. “massage removes toxins”. Thank you! I don’t think that came across is my post.
I spend a lot of time alone observing and thinking about CIPN, lymphedema, cold cap, gloves, and booties. And chemotherapy. When I stumbled across your article, I was relieved to be able to share. some of these thoughts. I mean them in the most sincere way and am searching for truth. Thank you for providing the space!
Diane, there was a glitch in my blog software and I am just getting your comments. My apologies, and thank you for taking time to share your thoughts! I appreciate the words from the front lines, and the more cautious thoughts about cold therapy. I understand being alone with your thoughts about all these topics. I’m so glad you found a mirror for them here, even for a moment. Bless you.
With the addition of frozen gloves and socks during treatment, objectively assessed CIPN was reduced from 81 to 28 percent in the hands and 64 to 25 percent in the feet of patients with breast cancer. Results from this study of 36 individuals were presented in a poster session during the 2016 Annual Meeting of the American Society of Clinical Oncology (ASCO), a gathering of 30,000 oncology professionals in Chicago.
The gloves and socks are stored inside a freezer set at -22 degrees Fahrenheit for more than three hours, typically overnight. A previous study by Ishiguro, though, showed that degree of freezing does not alter the efficacy of the gloves in preventing chemotherapy-induced nail toxicity in patients with breast cancer.
On the poster, the study’s authors stated that they were confident about the efficacy of the gloves and socks.
“This easy and safe strategy will be clinically applicable and improve the quality of life of cancer patients undergoing chemotherapy,” they wrote.
I especially like the easy part. So many patients are doing it on their own, as well.