A man has a stroke at age 35. He fully recovers, but is put on a lifelong prescription of anticoagulants. What is going on, and will he ever be able to receive the deep massage he wants?
In this episode of “I Have a Client Who …” we look at a common anomaly called patent foramen ovale. We discuss its connection to cryptogenic stroke (and we even dive into migraine for a hot second). Finally, we talk about some variables that inform the safety of massage therapy for clients taking anticoagulant drugs.
This episode sponsored by Anatomy Trains.
00:00 Narrator: 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.
00:39 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'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 episode came out of an interesting conversation that I was engaged in on Facebook, about the role of massage therapy for clients who use anticoagulants. And what the story reveals to us is there are many, many reasons people might use anticoagulants, and so our decision-making process about them really needs to depend on a bunch of different variables. So, here's this story, it's not an "I have a Client Who... " story, but it's almost one.
01:55 RW: I have a partner who is on blood thinners for life. He had a stroke at age 35, when a blood clot lodged in a tiny hole in his heart. So the issue was not a clotting issue, but the heart defect. They did not repair his heart, they just put him on blood thinners forever. He's 100% recovered and extremely active, but since I've never been able to find reliable information about massage for his case, I work with him conservatively. Firm, but nowhere near as firm as he would prefer. I asked my mother, a physician, and she said, "Well, I mean, just don't beat the crap out of him," except she didn't say "crap." So, that's the professional opinion I've been given. I'd love to know yours.
02:44 RW: And this comes from a massage therapist from Orange County, California, and I wanna say thank you so much for providing this really interesting story. It's a topic that I'm really intrigued by, and I also wanna invite you listeners to send me your "I have a Client Who... " stories. You can do that at email@example.com. That's ihaveaclientwho, all one word, all lowercase, @abmp.com. So, let's talk about this fella with a tiny hole in his heart. What I am pretty sure this massage therapist is describing... And again, this is an educated guess because I have not interviewed the actual person nor his healthcare team, but when she said a tiny hole in his heart, where I went to from that is a really interesting physical anomaly called patent foramen ovale.
03:46 RW: And here's the background on this. When a fetus is developing inside the uterus, and is developing a circulatory system, the septum is not completely fused. The blood crosses the atrium in ways that doesn't happen for people who are not hooked up to maternal circulation. And in the very early days of infancy, the flaps of the atrial septum are meant to come together and fuse into one unit so that the septum is complete and there is no capacity for blood to cross from the left side to the right side, or from the right side to the left side. However, for about 25% of the population, the flaps of the atrium do not completely seal, they leave a little bit of an opening, a hole in the heart, so that blood from one side, specifically blood from the right side, can cross over into the left side.
04:52 RW: Now, for the vast majority of people with this anomaly, this patent, which means, "still there", foramen, "hole", ovale, it's oval shaped. So, for the vast majority of people with PFO, patent foramen ovale, it's completely silent, and they may never know. It never causes any problems, it doesn't cause any symptoms, if they never have an electrocardiogram of their heart, they will never find out. Most of the time this is found out because people are getting their heart tested for some other reason. But, for some people, tiny little bits of debris, clots or other debris, from the venous part of the circuit that returns from the legs and the arms and the trunk, up the vena cava and into the right side of the heart, can crossover from the right atrium into the left atrium. And now, let's think about what happens if there's a blood clot or a little bit of debris in the left atrium. The next time the heart beats, it will get pushed into the ventricle, and then out into the aorta, and from there it could go anywhere.
06:00 RW: And where it goes, if it's really gonna cause a problem, is either into a coronary artery, causing a myocardial infarction or heart attack, or into the carotid artery, where it can cause a cerebrovascular accident, or an ischemic stroke. When this happens, it has kind of an odd profile, because in 35-year-old active young men who have no other predisposing factors for stroke, we don't expect to see stroke. In young women with no other factors, risk factors for stroke, we don't expect to see stroke. And so, when we see a stroke, or a heart attack, but usually it's a stroke, in a young person who is otherwise quite healthy, this is sometimes called a cryptogenic stroke. Crypto means "hidden", genic means "beginning". So, a stroke of hidden or mysterious origin, cryptogenic stroke.
07:00 RW: Cryptogenic stroke is not terribly common, but when it happens, it is often linked to patent foramen ovale. So, what do we do for this? We have a couple of options. There is, in fact, a procedure that snakes a catheter up the leg veins, and all the way into the heart, and through the patent foramen ovale, and then disks are implanted on either side of that opening in the heart, and then the catheter is withdrawn, and that basically seals the hole. But not everybody is a candidate for this intervention, and so when that's the case, they may be put on a lifetime commitment of anticoagulants.
07:42 RW: And we'll talk more about massage and anticoagulants in a minute, but before I leave the topic of PFO, I also wanna say that there is another association with PFO, and that is, for reasons that are not completely understood, migraine with aura. We see a statistical correlation between people who get migraine with aura and the incidents of patent foramen ovale. And there is, in fact, data that suggests that repairing the patent foramen ovale may have a positive impact on the incidence and severity of migraine. The third part of that triad is migraine with aura, patent foramen ovale and cryptogenic stroke, and it turns out that that is a pattern that appears particularly in young women, that young women with migraine have a higher risk for cryptogenic stroke than others do.
08:43 RW: Now, before we leave this topic entirely, I do wanna point out, it's important to point out that this is a relatively rare situation, cryptogenic stroke, or a stroke related to a patent foramen ovale. The vast majority of ischemic strokes in this country are related to cardiovascular disease, arrhythmias, including atrial fibrillation, plaque and debris accumulating in the carotid arteries. These are the origins of most ischemic strokes in this country, but cryptogenic stroke is a factor. Particularly, we look for this as an explanation when we see a stroke in young and otherwise healthy adults.
09:23 RW: What about massage for people who are on long-term blood thinners, or long-term anticoagulants? The first thing I wanna say about that is that drugs that manage blood clotting come in essentially three different strategies. One is thrombolytics, those are the clot busters, and we don't usually see those outside of a hospital setting. Another is anticoagulants, and those are drugs that interfere in the clotting cascade, in various kinds of ways that they can do that. And the third is antiplatelet drugs, and these are drugs that interfere in the activity of platelets, that of course initiate the whole clotting process. And you probably are familiar that a really common antiplatelet drug is aspirin, and probably the most common anticoagulant drug is something called Coumadin.
10:17 RW: And it's always a bit of a balancing act to figure out what is the lowest possible dose to get the best possible results with anticoagulants, because if we have a dose that's too low, then they don't work, and then this person is at risk for more iterations of this cryptogenic stroke, but if the dose is too high, then this person becomes at risk for uncontrolled bleeding. So, one of the really, really key questions to ask our clients, anyone who uses anticoagulants is why? And for how long? And what side effects do you have? We wanna know why, because anticoagulants imply some problem with blood clotting, and this is relevant for massage therapists, we should know. We wanna know for how long, because this will let us know if the client is familiar with how this drug affects their function, and if they have a prognosis where the day will come when they will get off their anticoagulant. And the third is... The third question about side effects, let's us know about whether they experience a really, really common side effect of anticoagulants, which is bruising.
11:35 RW: So, we're constantly irritating our capillaries. We bang, we [11:38] ____, I bang my elbow on door jams, and I hit my head on low beams, and I stub my toe really hard on things. This is just how [chuckle] I sort of navigate my environment, and so if I were using an anticoagulant, I could be bruising a lot. And that's something that we see in people who are using drugs to manage blood clotting, is a very, very heightened chance of them bruising. Now, some people really don't have that as an issue, and it's not a big deal, and they have virtually no side effects, but other people find that anticoagulants means that they, you know, bruise like a peach. So, to come back to the client that we're talking about here, the guidance about massage, we know that he's taking the anticoagulant because of this PFO. We know that he will be taking it for the rest of his life. We don't have information here in this description about whether he has side effects related to his anticoagulant, but what we do know is that he's a 100% recovered from his stroke, and he is extremely active.
12:43 RW: That is a key piece of information, because like with so many things around pathologies, we wanna make sure that whatever massage we offer does not challenge a person's capacity to manage the environmental demands that we make with our work. And so, if this client is running, if he's playing sports where he may get knocked around, if he's doing any kinds of activities that would give us some sense of whether he bruises a lot, that is really, really useful information. And my advice to this massage therapist is to check in and analyze what his bruising is like, and then to... If it feels safe, and he doesn't bruise easily, then we can begin to press against those boundaries just a little bit, incrementally. We're not gonna break out the elbows and reconstruct his thigh muscles, or whatever, all in one day. But, conceivably, if he's that active and young and healthy, and he's not bruising, then more intense massage could be appropriate.
13:53 RW: That would not necessarily be true for someone who uses anticoagulants for other reasons, and that's why we cannot rubber-stamp decisions about massage therapy. So this is a really fun one, we got to talk about patent foramen ovale, and we got to talk a little bit about migraines, and we got to talk about making incremental changes in our massage based on how our clients respond to our work, and I hope this was really helpful. In the show notes for this episode, I'll give you a couple of links to some really interesting YouTube videos that show patent foramen ovale repair, also a link to an interesting article about migraine and aura, and young women with cryptogenic stroke and PFO. And finally, if we can manage it, I'm hoping to link you to a PDF of an article I wrote on massage therapy and PFO that goes into much greater detail than we did here, but it dates all the way back to 2007.
14:56 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 firstname.lastname@example.org. 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.
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