The Conscious Massage Therapist

In our work as Massage Therapists, we would all probably say that one of the main reasons this career appealed to us initially was the opportunity to not only work closely with people, but also to have a lasting impact on their overall well-being. We love to help people. Of course, some of us were likely very attracted to the technical skill of the job and the demand for problem solving, critical thinking, and piecing together information for complex musculoskeletal conditions to provide treatment plans for our patients that will yield favorable clinical outcomes. Whether it is the compassionate side of you, or the analytical side, the result is that we work with humans and help them to reach their health and wellness goals. What a great feeling! While in school, we focused mainly on the body, naturally, because we were studying to become body workers. We also learned about therapeutic relationships of course because when working with people, their physical and mental health are so intertwined that we have to be aware of all aspects of this person in our treatment room and be sure we have the soft skills of communication, empathetic listening, decision making, and rapport building in order for our patients to get the most out of their treatment plans. It is safe to say that Massage Therapists as a whole, have excellent soft skills, and are well-equipped to work with people from all walks of life. That is not to say that Massage Therapists don’t come with their own biases, life experiences, and blind spots that may limit their abilities with certain populations. This is why we are constantly learning, improving, networking, and working towards being the best therapists we can for the patients we serve.

This issue we have brought four incredible Massage Therapists from Ontario who are doing great things in their practice and for the massage community. These four women have unique areas of focus in their practices and their patients are so lucky to have therapists who have taken time, energy, and resources to become educated about things that were merely touched upon in school but affect such a large proportion of our population. Our aim through these articles is to open your minds to things that we likely encounter all the time, and how to be mindful of these things to improve your own practice. I am not suggesting that we all need to become experts in all of these areas, especially if we already have a well-established niche and some of this does not apply to our practice. As you will see, these are things that almost every therapist will encounter at some point in their practice and having an understanding about how a patient may be affected and how your treatment plans and referrals may change, can only make us better for our patients. I am talking about trauma, cancer, hormones, and lymphedema.

One of our contributors has a practice that she has branded a being trauma-informed. What does that mean? Are we all trauma-informed? Her article focuses on how her own trauma was actually affecting her practice, how we need to be aware of our own triggers as therapists, and how to understand our own trauma to be sure we can have space for our patients’ trauma. Although it may seem that this is outside of scope, trauma-informed is a term that means just that. We are not mental health professionals but we do know that trauma will have a profound effect on how a person will respond to treatment, how they will comply with their treatment plans, how they communicate etc. Understanding this and being trauma-informed will allow therapists a deeper understanding as to why certain techniques may or may not be beneficial at certain times and allow insight to how to work with individuals versus strictly bodies.

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Let’s talk about cancer. Can anybody say that they have not encountered a person dealing with a cancer diagnosis, the side effects of cancer treatments, or recovering from surgery due to cancer? It is unlikely that you don’t know someone who has been affected by cancer in some way. The article on oncology massage really focuses on how aware we are of how to adapt

our patient interactions, treatment goals, and treatment plans for someone who has been through cancer treatments or is currently dealing with cancer. This one will allow therapists to be much more mindful in their intake interview and not take each symptom at face value. Same with lymph. As Massage Therapists, how much do we actually know about our lymphatic system? Do we know how much it affects every other function in our body? Aside from the basic manual lymphatic drainage techniques we learn in massage school, our understanding of lymph may not be adequate to deal with patients who have a dysfunction in their lymphatic system. This article gives a brief overview of the system and may encourage you to either learn more or create a referral network to have a lymphedema therapist in your back pocket. The work they do is so important.

Lastly, we have a chat about hormones. This may seem not important to massage therapists, but our contributor would disagree. She has been creating courses and aiming to educate Massage Therapists about hormone cycles, specifically with female bodies, and how it may affect communication, mood, tolerance for pain, or exercise. Like trauma, we are not expecting Massage Therapists to give advice that should be left to an endocrinologist, but we are looking to have you be mindful of all of the aspects of a human that may affect the world of body work.

Massage Therapists are a rare breed of human that are both healthcare workers, and service providers. Our constant assessment processes are vital in ensuring that we adapt our treatment approaches to allow for the variance that comes with working with humans. Physical and mental trauma may have an effect on a person that varies from day to day, pathologies such as cancer will of course have an impact on a person’s well-being, and any bodily processes such as the cyclic nature of hormones, will have an affect on a person. We spend a significant amount of time with our patients and we have the unique opportunity to shift our treatments to allow for the normal human experiences that our patients deal with from day to day. We have all seen the term “meet you where you are” and this is exactly what we are aiming to do. Be the best therapist you can be. Be mindful. Be conscious. 

Massage for people affected by cancer has always been in our treatment rooms, even if we haven’t paid it too much attention. With 2 out of 5 Canadians being diagnosed with cancer, all massage therapists, in all practice settings, must be ready to work with the diverse and often persistent side effects of cancer treatment.   
 
To best illustrate how we can adapt our treatments we will look at intake and treatment through the lens of a client.  Cory, 48 years old, is a runner who often takes part in 10 km competitions.  Two years ago, he was diagnosed with colon cancer.  It has been almost a year since he completed all the recommended treatments including surgery to remove a small part of his colon, chemotherapy and radiation.  Once his energy had improved, Cory returned to running.  Although used to deep tissue massage for tight leg muscles, Cory has come for a massage for persistent low back pain and mentions that burning in his feet makes working out more challenging.  
 
What might Cory’s massage look like if his cancer treatment wasn’t part of our intake and planning?  Given the presenting symptoms, a massage therapist might start with focused, deep treatment to Cory’s low back, glutes and hip flexors.  The burning in his feet and low back pain could be explained by a lifestyle with too much sitting and running.   Without careful probing during intake, the proposed treatment could overlook some critical information that ensures safe treatment adaptations. 

A not-yet-oncology-aware massage therapist might not know to expand their usual intake questions to properly assess how side effects of cancer treatment could be contributing to Cory’s presenting signs. Which brings us to the question of how much do we really need to know to treat someone affected by cancer?  Following are some of the lines of inquiry necessary to work with Cory and to pique our curiosity to learn more. 
 
Surgery, the most common primary cancer treatment, may result in often predictable short and long-term side effects. According to Cory, other than some pain and fatigue in the weeks following surgery, he didn’t have the bowel and bladder changes that could have occurred.  As part of our inquiry, we can explore the possibility that the surgical incision and resulting scar may be impacting his low back.  This information will not only help to streamline our assessment and treatment, but it is also part of the education we bring to our clients:  Cory didn’t know that scars can impact function.  
 
During chemotherapy Cory mentions that he lost his hair, had mouth sores and was very tired.  He also had many of the classic signs of chemotherapy-induced peripheral neuropathy (CIPN) such as cold and tingling in his hands and feet.  Cory had forgotten that chemotherapy could cause persistent and long-lasting side effects and the likelihood that the burning in his feet is caused by the neurotoxic impact of chemotherapy. Before addressing this symptom, the massage therapist makes a mental note to further explore CIPN, whether there are precautions to consider and how best to provide massage.   

Skin reddening and peeling are common side effects of radiation and, once healed, it is easy to overlook its deeper impact.  Densification can occur in every structure within the field of radiation including muscle, fascia and organs as well as blood and lymph vessels.  Bringing 3-dimensional awareness to massage treatment planning will widen the therapist’s thought process and critical thinking.   
 
The densification after 20 sessions of radiation Cory underwent could be a contributing factor to his low back pain. The irradiated area can also often lead to fragile tissues and damaged lymph vessels and nodes.  This knowledge signals a need for precautions during massage with careful use of pressure and stroke direction.   
 

Did you know? 
There is a lifetime risk of developing lymphedema for anyone whose lymphatic system is compromised by cancer treatment including: 

1. surgical removal of lymph nodes 

2. radiation 

A careful intake process for someone affected by cancer naturally leads to consideration of contraindications and precautions.  Cory’s cancer treatment ended a year ago and there are no signs of absolute contraindications such as blood clots and infection.  There are, however, many precautions that need to be considered.  

• CIPN may reduce sensory awareness requiring very cautious use of heat, cold and pressure. 

• Persistent inflammation that can last years after radiation treatment may cause tissues to be sensitive and easily overworked, requiring careful adaptation to pressure and treatment duration in the irradiated area. 

• The compromised lymphatic system is best treated by a therapist trained in lymphatic drainage. 

• Cancer metastasis can cause pain and requires massage adaptations until medical testing confirms or clears diagnosis  

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Think back to the not-yet-oncology-aware treatment plan.  Transpose the deep pressure on Cory’s back, glutes and hip flexors onto an area that we now know has been affected by surgery, chemotherapy and radiation and imagine the potential adverse side effects from a massage that overworks damaged tissues.   
 
It is not always clear how to proceed with treatment when a client presents with the complex and overlapping side effects of cancer treatment.   A well-planned massage will proceed slowly and cautiously and take into consideration all contraindications and precautions.  As well, careful monitoring of our client’s reactions and tissue changes can help to guide our work.  Finally, follow-up within a few days of the massage is an essential step to track our client’s reactions to their treatment.   
 

We have grown accustomed to categorizing and hyper-focusing our work.  Sports massage works on injury prevention and recovery.  Prenatal massage provides treatment for the physical changes that occur during a relatively short period of time. Providing massage for people affected by cancer is, by necessity, geared to the whole person.  Each person’s physical and emotional reactions to cancer and its treatment are unique.  Although there is no template upon which to build a treatment plan, foundational knowledge of the side effects of cancer treatment will allow us to provide informed care. 
 
As massage therapists we work alone in a room with our client.  The onus is on each of us to ensure that our knowledge is sufficient to work with the complexity of cancer treatment side effects.   We don’t have to know everything, but we do need to know when we don’t know enough.  Small efforts in learning about cancer treatments and the implication for our work as massage therapists will go a long way in ensuring safe treatment for clients with any type of cancer at any stage of treatment and beyond. 
 

Recommended Reading

Oncology Massage: An integrative approach to cancer care; Penny and Sturgeon (Handspring 2021)
Traumatic Scar Tissue Management: Principles and practice for manual therapy; Ryan and Keeney Smith; (Handspring 2016)