A client who has never had massage before calls to make an appointment. He has a history of “grand mal” seizures. What does the massage therapist need to know to be safe with this client? We go through a short list of important questions.
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0:00:00.0 Speaker 1: Ruth Werner's best-selling book, A Massage Therapist's Guide to Pathology is a highly regarded comprehensive resource that sets the standard for pathology education. Written for massage therapy students and practitioners, this ground-breaking resource serves up a comprehensive review of the pathophysiology, signs, symptoms, and treatment of more than 500 diseases and disorders. Learn more at booksofdiscovery.com.
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0:01:17.2 Ruth Werner: Hi, and welcome to I Have A Client Who, pathology conversations with Ruth Werner, the podcast where I will discuss your real life stories about clients with conditions that are perplexing or confusing. I am Ruth Werner, author of A Massage Therapist's Guide to Pathology, and I have spent decades studying, writing about, and teaching about where massage therapy intersects with diseases and conditions that might limit our client's health. We almost always have something good to offer even with our most challenged clients, but we need to figure out a way to do that safely, effectively, and within our scope of practice. And sometimes, as we have all learned, that is harder than it looks. Today's I Have A Client Who story comes from a massage therapist in Nebraska who shares this.
0:02:10.3 RW: Hi, I had a new client reach out to me regarding getting their first massage. They have a significant history of grand mal seizures, however, it's been several years since the last seizure event. In fact, his condition has improved enough that he has returned to driving. I've been reading several articles online regarding massage and epilepsy, are there any resources you would recommend prior to me seeing this client? I've done an extensive verbal history and I'm gonna have him get a note from his MD. Are there any other considerations I should be talking about?
0:02:45.7 RW: I followed up with this massage therapist and I got a little more information. The client is in his early 50s, he has never received massage before, another massage therapist made the referral, he's been seeing a chiropractor, he says he does not always know when he's going to have an episode, but his wife does, and the massage therapist just wanted to get as much information as possible before taking on a client with a history of seizures. I wanna make sure to clarify a couple of things that come up in this story that I've shared so far, but first, let's talk about seizures in general, and epilepsy in particular. A seizure is the result of dysfunctional synaptic activity in the brain. When a person who is prone to seizures has the right kind of stimulus, the interconnecting neurons in their brain are activated in such a way that they release this big burst of excess electricity and this triggers nearby neurons and so on, the reaction can either stay localized or it can spread all over the brain. There is an astonishing variety of types of seizures, and they have been the subject of a lot of study, because we find that it is possible to refine treatments, depending on what types of seizures a person experiences.
0:04:03.0 RW: I also wanna point out that seizures are not uncommon, almost a tenth of all people in the United States has a seizure at some point or other. A lot of times this happens in childhood as a result of high fever, and these are called febrile seizures, and they are seldom serious, they usually don't have long-term consequences. Seizures can be related to traumatic brain injury, stroke, Alzheimer's disease, and other central nervous system issues, but for the client we're talking about in this context, it seems clear that with his history, he probably has epilepsy. And this is identified when a person has at least two non-febrile seizures at least 24 hours apart. I always get kind of a kick out of looking at the origins of words in pathology, and I have to tell you that the origin of the word Epilepsy is a little disappointing. Epi, of course, means upon, but lepsies just means seizure. So, that's not terribly elucidating, but one interpretation of the Greek root for lepsies suggests that it means attack or take a hold of, and that can give us a sense of what a seizure experience is like, especially since in the early days of Western medicine, seizures were thought to be a sign of demonic possession.
0:05:26.4 RW: Back when I was in massage school, and even when I was first writing early editions of the textbook, seizures were roughly divided into two categories, grand mal and petit mal events. And the idea was that grand mal seizures involved the whole body and petite mal seizures were more localized, these delineations were fabulously unhelpful to people who live with seizures, and as we have learned more and more about what causes these central nervous system lightning storms, the language about seizure descriptions has become more precise. There is an organization called The International League Against Epilepsy, and in 2017, they published some new classifications of seizures to try to be more accurate in the description of what kinds of neurological issues are involved and where. So, seizures are now described by three main variables, where in the brain they begin, the person's level of awareness while they are happening, and other, specifically whether the seizures involve motor symptoms or not, or what kinds of motor symptoms we see.
0:06:35.1 RW: Obviously, we don't know exactly what type of seizure the client described in the story has, but by the delineations from The International League Against Epilepsy, it's probably fair to suggest that he experiences generalised tonic-clonic seizures. That means the seizures involve his whole brain with uncontrolled jerking, that's the clonic part of the seizure, along with muscle rigidity, and that's the tonic part of the seizure. And then very often, these generalised tonic-clonic seizures will conclude with the person passing out and being unconscious for a period of time. Seizures are typically treated with medication, anti-seizure or anticonvulsant drugs that interfere with synaptic activity. In some cases, surgery can be done to sever certain connection spots in the brain. One of the reasons it's important to limit seizures through medication or surgery is that these episodes can ultimately change cardiovascular autonomic reflexes. In other words, it can become progressively more difficult for a person who has many seizures to maintain appropriate heart rate and blood pressure. And if this process isn't interrupted, it can lead to a complication called Sudden Unexplained Death in Epilepsy or SUDEP.
0:07:58.3 RW: Thankfully, this client appears to have his situation under good control. He reports that he hasn't had any seizures in several years, he's allowed to drive and that he has no other health situations. So what else does this massage therapist need to know before they can work with this client? If you are a frequent listener to I Have A Client Who, you might be able to predict what I'm about to say. Our contributor today says they plan to have him get a note from his MD, and my response is as always, why? Because it makes a big difference to ask permission from a doctor to work with a client as opposed to getting information from a doctor in order to work more effectively. So my hope is that the information this massage therapist wants to learn from the client's healthcare team is about his treatment plan, what medications he takes, what his triggers are, and any other issues that the massage therapists can use to make appropriate accommodations as they construct a treatment plan, and of course, this is very different from asking Dr. X for permission to work with Mr. Y.
0:09:01.1 RW: One important piece of information that I did not find out in my communications is, if this client is using medication to manage his seizure disorder, this could be an important consideration, because the medications that are used for epilepsy are drugs that suppress synaptic activity, in other words, they tamp down nervous system responsiveness. So those lightning storms never have a chance to really get started. Anti-seizure medications tend to have a lot of side effects, they can make people feel really fatigued or loopy, and that could be an issue if massage therapy adds to that sense of heaviness and fatigue. So finding out what kinds of medications he's using, if any, to manage his seizure disorders is an important step in designing a safe treatment plan for this client. Another really important piece of information is, what kinds of triggers this client has found himself to be sensitive to? Some people with epilepsy do not tolerate flickering light, for instance, so this might mean not using a ceiling fan, or if there are fluorescent lights, turning those off and using an alternative light source.
0:10:11.6 RW: Some people are sensitive to a certain scents, some are sensitive to certain kinds of sounds or music. So, the more information we can gather about what this client's safest environment is, the more confident we can be in being able to provide that for him. Beyond that, the happy news is that epilepsy or other kinds of seizure disorders that do not accompany underlying issues, have no particular cautions or contraindications for massage therapy. However, even though it is extremely unlikely since this person hasn't had a seizure in quite a long time, I really recommend that this massage therapist develop an action plan just in case something unexpected happens. And this action plan would include what the client would want them to do if he has a seizure during a session, specifically, who does the client want the massage therapist to call in addition to 911 if he has an event. The other main issue in working with clients who might possibly have a seizure while they're on the table is figuring out a way to safely get them off the table and onto the floor, and then to move other furniture away so that they are at less risk of having an injury.
0:11:27.1 RW: There's almost no research about massage or other manual therapies in the context of people who have seizure disorders, but there was one study in 2006 that got a remarkable result, and I will link to it in the show notes. In this study, 77 participants who were not candidates for surgery or they had failed surgeries to correct their seizure disorders, or who were not responsive to anti-epileptic drugs, all of these 77 people were split into two groups. One group received their regular treatment, their treatment as usual, and the other group received their treatment as usual, plus reflexology treatments to the hands and feet. In the massage group, the median baseline seizure frequency decreased from 9.5 to 2. The medicated group also saw a decrease in seizure frequency, but it was just a fraction of what was seen with the reflexology group. Now, I wanna point out that this study was done with people for whom the medications didn't work well and they were not good candidates for surgery, in other words, these were people with the most severe possible presentation of seizure disorders and they were not treatable by other means, and so for them, reflexology was essentially a last ditch option, and it had a remarkably positive effect.
0:12:50.8 RW: This doesn't describe the person in our story today, because he's not dealing with frequent seizures, and so, we're not looking for massage therapy to reduce the frequency of his episodes. When I brought up the idea of an action plan with the contributor today, their response was, Okay, I've been running through this idea for such an event, I have 20 years or more as a physical therapy assistant, but now I'm a solo massage therapist, and I no longer have a nurse at my disposal, so I just wanted to gather as much information as I could before taking on a client with a history of seizures. Here's a client with what sounds like pretty successfully managed epilepsy. What do we need to know to work safely? We need to know the client's triggers, we need to know the client's medications, because sometimes these cause side effects that might mean he needs more time to transition back to full speed after his session. And we need to know the client's preferences for what to do if he has a seizure during his massage appointment. Beyond that, consulting with the client's doctor is a great idea, just so everyone is on the same page, but I really feel that this massage therapist has their ducks in a row and this client is gonna get a great treatment.
0:14:05.9 RW: Hey, everybody, thanks for listening to I Have A Client Who, pathology conversations with Ruth Werner. Remember, you can send me your I Have A Client Who stories to email@example.com. That's ihaveaclientwho, all one word, all lowercase @abmp.com. I can't wait to see what you send me, and I'll see you next time.