A pregnant massage client, who is consistently late and unusually demanding, wants deep—really, really, deep pressure on her hip. The tricky part? She has been diagnosed with complex regional pain syndrome: a condition that often begins with an injury but complicates to chronic, intractable, and sometimes spreading pain. And massage can make it worse.
Pocket Pathology: abmp.com/abmp-pocket-pathology-app
Duman, I. et al. (2009) ‘The efficacy of manual lymphatic drainage therapy in the management of limb edema secondary to reflex sympathetic dystrophy’, Rheumatology International, 29(7), pp. 759–763. https://doi.org/10.1007/s00296-008-0767-5.
Lee, J. and Nandi, P. (2011) ‘Early aggressive treatment improves prognosis in complex regional pain syndrome’, The Practitioner, 255(1736), pp. 23–26, 3.
Safaz, I. et al. (2011) ‘Manual lymphatic drainage in management of edema in a case with CRPS: why the(y) wait?’, Rheumatology International, 31(3), pp. 387–390. https://doi.org/10.1007/s00296-009-1187-x.
Sayegh, S.A. et al. (2013) ‘Mirror therapy for Complex Regional Pain Syndrome (CRPS)-A literature review and an illustrative case report’, Scandinavian Journal of Pain, 4(4), pp. 200–207. https://doi.org/10.1016/j.sjpain.2013.06.002.
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0:01:35.0 RW: 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'm 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. This week's episode is about a condition I'm a bit familiar with, partly because it's on my short list of conditions I hope I never have to deal with, but it also involves a situation that is new to me because it's not about a typical hands-on massage therapist. The contributor this week is an Ashiatsu therapist who does massage mainly with their feet. They use a massage table, they have poles overhead for support.
0:02:49.7 RW: This client story is from several years ago, so some of the details have been lost, but it's really fascinating, and it goes like this. I had a client who was pregnant and in her third trimester, she had been diagnosed with CRPS either right before or just after getting pregnant. I wasn't sure where. I assumed, since I didn't know anything about CRPS at the time, that it was where she asked for work, but that seems weird now, I know she moved and walked cautiously and slowly. She complained of major pains where she requested deep massage in her sacral hip glute area and attachments, not so much lumbosacral, but she really loved, needed, demanded pressure directly in the femoral acetabulum crux. There's a move in Ashi and prone to laterally rotate the hip with a bent knee and get a little traction by pushing, and you hold the foots arch over and around the greater trochanter, and she just wanted my heel right there with what felt like to me, enough pressure to push her off the table.
0:04:02.6 RW: I didn't do this much, of course, but she literally was asking for that amount of pressure. I treated all over, glutes lateral rotators, sacral joint and ligaments, some hip flexors and her quadriceps, she also said her shoulders and neck were intensely sore and she wanted to work there because she would get headaches. This client always showed up to her massage a few minutes late, appearing to be barely holding on to sanity, and she always left my studio with a sleepy smile and telling me I was an angel with a gift. So I guess I did enough pressure, but I was always uncomfortable during the massage, not knowing if it was safe to give her the pressure that I did. After the baby was born, I didn't see her anymore.
0:04:54.1 RW: Okay, so there are a few things to unpack here, clearly we've got a couple of boundary issues around this client being late a lot and asking for extra pressure and so on, and those are things that it's up to this massage therapist to work on with their own communication skills. We all have room to grow in those departments. But then there's this huge issue about CRPS, and that is frankly a great big deal. And from this little bit that this massage therapist has shared with us, it's hard to understand if CRPS was really going on. Now, I'm always willing to be wrong about these things, and in the interest of believing what people say about their health and definitely about their pain, let's take a look at CRPS and then we'll see how it might apply to this particular client.
0:05:48.0 RW: CRPS is a disorder that has accumulated a few different names over time, that's often a sign that we might not understand it well. This condition or things very similar to it have been called through history, causalgia, reflex sympathetic dystrophy syndrome, sympathetic maintained pain syndrome, shoulder hand syndrome, Sudeck atrophy, and its modern and most widely used name now, complex regional pain syndrome or CRPS. I'll say that again, complex regional pain syndrome.
0:06:26.4 RW: CRPS and all of its aliases and its two subtypes and its associated partners in crime, these conditions show us some important links between the autonomic nervous system that helps us with our in voluntary and reflexive stress or relaxation responses, and our somatic nervous system that sets up our voluntary movement. Did you hear a reference to the sympathetic nervous system in a couple of those names? Reflex sympathetic dystrophy syndrome. That's how I first learned about this condition. And boy, that sounds like a sympathetic reflex that leads to problems with tissue growth, which is in fact a good description of this condition.
0:07:09.9 RW: There's another name, sympathetic maintained pain syndrome. Take a second and think about what that implies. The maintained pain is the big issue here. This whole process is pretty complicated, so to be both succinct and accurate, I'm just gonna share a couple of paragraphs from my book to help explain this. When a person receives a stimulus, a sensory neuron carries that information to the spinal cord and then up to the brain. If the stimulus is something soothing and welcomed, like a smooth, confident Effleurage stroke, the reaction from the brain is a relaxation response in the tissues.
0:07:49.3 RW: But if the stimulus is threatening or causes tissue damage and nociception, the brain-mediated reaction is likely to be a sympathetic response with associated changes in blood flow. In CRPS, an initial trauma, often to a hand or a foot, but really anywhere on the body can be affected, elicits a sympathetic response in the tissues from the nervous system. CRPS is often associated with high velocity trauma like a bullet or shrapnel wounds, but it has also been seen with minor strains and sprains and as a post-surgical complication, and with fractures, even at injection sites, following strokes, as a consequence of a disc problem or sometimes with no identified causative trauma at all. Regardless of the trigger, potential or real injury creates a sympathetic response in the tissues with local inflammation. This reinforces pain signals, it hurts, and now we have a positive feedback loop with an exaggerated inflammatory response. Nociceptors in the affected area and in their connections in the spinal cord become increasingly sensitized.
0:09:05.9 RW: Ultimately, the experience of pain becomes a self-fulfilling prophecy, a person hurts, which causes stress and makes the pain worse, and the healing processes that should interrupt this sequence are unable to overcome the power of this vicious circle. Eventually, the physiologic changes that occur when a specific part of the body is stuck in a sympathetic loop cause secondary damage, which may eventually be irreversible, circulation changes affect the skin, muscles atrophy, the bones become thin, joints may fuse, part of this chronic pain scenario involves both peripheral and central sensitization as the neurons grow new connections to receive messages about damage, they become more easily triggered by nociceptive signals.
0:10:00.7 RW: This can broaden the perception of the sensory field, in other words, it feels like the pain is spreading. A larger and larger area of the body is affected, this leads to more sympathetic responses, inflammation and tissue changes, this mal-adaptation of the central nervous system means that the pain cycle seen with CRPS has the potential to spread proximally on the affected limb, to the contralateral limb and elsewhere. If I may say, yikes. And that is why this condition is on my short list of things I hope I never have to deal with. CRPS can cause structural and chemical changes in the nervous system that make people more sensitized to incoming messages about arm, that's nociception, of course.
0:10:51.4 RW: And then the response is to flood that area with protective mechanisms that ultimately do more damage than good, with inflammation and guarding and other tissue changes. Plus the brain gets confused about that source of information and begins to assign a larger and larger receptive field. So it feels like the pain is spreading. CRPS is notoriously hard to treat, partly because the window of opportunity for best results, which is just in its earliest stages is pretty short because those early stages are hard to identify, it just feels like an injury hurts for longer than one might expect. By the time the neurological changes have become ingrained, treatment gets much more complicated, usually involving combinations of psychotherapy, occupational therapy, mindfulness training, along with nerve blocks, intrathecal pumps to put analgesics directly into the central nervous system, and sometimes a sympathectomy, the severing of sympathetic neurons.
0:11:55.2 RW: I've spoken with a few people with various types of CRPS and deep pressure at the site of their focal pain is pretty much the opposite of what they ask for, and that's why I'm a bit surprised about the client in our story today. We don't know exactly where her pain was focused with her CRPS, but she craved pressure deep in her hip, so much pressure that the therapist was worried about pushing her off the table or even about hurting her baby. Ultimately, the client was happy with her sessions and the baby was fine.
0:12:29.4 RW: At this point, all we can do is speculate about this client, does she really have CRPS? Was it in her hip? Maybe she had some kind of unusual sensory experience that made the counter pressure of deep, deep touch somehow satisfying and positive. I assume she wasn't on heavy duty pain killers because of the baby, but really we just won't ever know for sure. There's a little bit of research about massage and CRPS mostly focused on lymphatic drainage. This kind of technique gets decent results, but they don't last long, at least in the small scale studies that have been done so far.
0:13:09.3 RW: Doctors may recommend self-massage to patients to keep sensation as healthy and positive as possible, if this problem is found early enough, that they can tolerate this kind of touch. And if the client can tolerate it, then we can definitely be part of that strategy. There's also a field of therapy that I find pretty fascinating that uses mirrors, this is used in physical therapy and occupational therapy, possibly sometimes in massage. The idea is that if someone has a painful hand, for instance, then we set up mirrors on the healthy hand, so it looks like the painful one, but it's not the painful one, and we massage it, and through some amazing connections in the brain called mirror neurons, the damaged hand may feel better. The data on this is promising, but it is not a replacement for other interventions.
0:14:03.8 RW: My conclusion on this particular I Have a Client Who... Story is kind of inconclusive. I trust that the client had CRPS, at least she said she'd been diagnosed, but it was certainly a different experience of it than what we see most of the time. This massage therapist who was very generous about sharing the story, they did the best they could, but they felt pushed beyond their comfort levels in terms of giving pressure, this concern was magnified by the fact that the client was in her third trimester of pregnancy, and the therapist was using their feet. Even so it all worked out okay.
0:14:39.0 RW: The client was happy, the baby was healthy, and the massage therapist is relieved that this client has moved on and is no longer seeing them. I know that if the massage therapist had known more about CRPS when all of this happened, they would have gathered more information before proceeding. Maybe the initial injury was to a wrist or an ankle, and it just didn't figure into the massage sessions at all, even so, taking extra precautions to make sure the client feels safe and as free from pain as possible is a big part of what we do. So with someone who has CRPS, that is likely to involve extra bolstering and care when they move around on the table, it's hard to make these appropriate accommodations if we're not sure we're getting all the key information. If you have a client with CRPS, I am willing to bet they won't be asking for super deep pressure. But if they do, this would be a good time to get just as much information as you can about their situation, so you can be sure that they are as comfortable as possible and able to give you instant and accurate feedback about their comfort.
0:15:47.8 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 Ihaveaclientwho@abmp.com. That's Ihaveaclientwho, all one word, all lower case @abmp.com. I can't wait to see what you send me and I'll see you next time.