Ep 308 – CTE: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

An image of two football players standing eye-to-eye.

A client is a former NFL linebacker with CTE (chronic traumatic encephalopathy). What is going on inside his head? And is it safe for the massage therapist to work with him?

CTE is part of a range of head injuries that includes traumatic brain injury, concussion, and post-concussion syndrome. We don’t have a lot of information about massage therapy in this context, but we can get enough information to look for good ways to help.


Pocket Pathology: https://www.abmp.com/abmp-pocket-pathology-app

Brain Banks | Concussion Legacy Foundation (no date). Available at: https://concussionfoundation.org/programs/brain-banks (Accessed: 10 January 2023).

Burns, S.L. (2015) ‘Concussion Treatment Using Massage Techniques: a Case Study’, International Journal of Therapeutic Massage & Bodywork, 8(2), pp. 12–17.

‘Chronic Traumatic Encephalopathy (CTE): Overview, Background, Timeline and History of CTE’ (2023). Available at: https://emedicine.medscape.com/article/2500042-overview#a2 (Accessed: 10 January 2023).

Frequently Asked Questions about CTE | CTE Center (no date). Available at: https://www.bu.edu/cte/about/frequently-asked-questions/ (Accessed: 10 January 2023).

Living with CTE | Concussion Legacy Foundation (no date). Available at: https://concussionfoundation.org/CTE-resources/living-with-CTE (Accessed: 10 January 2023).

Massage & Bodywork - September | October 2014 (no date). Available at: http://www.massageandbodyworkdigital.com/i/365665-september-october-2014/42? (Accessed: 10 January 2023).

Post-Concussion Syndrome: Symptoms, Treatments, Tests, Recovery, and More (no date). Available at: https://www.webmd.com/brain/post-concussion-syndrome (Accessed: 10 January 2023).

Richer, A.C. (2017) ‘Functional Medicine Approach to Traumatic Brain Injury’, Medical Acupuncture, 29(4), pp. 206–214. Available at: https://doi.org/10.1089/acu.2017.1217.

What is CTE? | Concussion Legacy Foundation (no date). Available at: https://concussionfoundation.org/CTE-resources/what-is-CTE (Accessed: 10 January 2023).

Author Images: 
Ruth Werner, author of A Massage Therapist's Guide to Pathology.
Ruth Werner's logo, blue R and W interlinked.
Author Bio: 

Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology, now in its seventh edition, which is used in massage schools worldwide. Werner is also a long-time Massage & Bodywork columnist, most notably of the Pathology Perspectives column. Werner is also ABMP’s partner on Pocket Pathology, a web-based app and quick reference program that puts key information for nearly 200 common pathologies at your fingertips. Werner’s books are available at www.booksofdiscovery.com. And more information about her is available at www.ruthwerner.com.   

Full Transcript: 

0:00:01.2 Ruth Werner: Hey, "I Have a Client Who... " listeners, did you know I have a growing library of NCB-approved one-hour online self-paced continuing education courses that you can do any time, anywhere? Well, now you know. Current classes include, What's Next: COVID-19 Updates For Massage Therapists, and, A Massage Therapist's Introduction to Pharmacology Part I. And brand new, A Massage Therapist's Introduction to Pharmacology, Part II. Classes are $20 each, and they confer one hour of continuing education credit. Wanna know more? Visit my website at ruthwerner.com and check it out. Be sure to sign up for my mailing list so you'll never miss a new class. 




0:00:56.0 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. 


0:01:42.5 RW: Today's "I Have a Client Who... " story relates to a football injury. No, it is not the sudden cardiac arrest that we saw with Damar Hamlin recently, it is the result of repeated head trauma, a condition called Chronic Traumatic Encephalopathy or CTE, and our story goes like this. So I have a new client, former NFL linebacker who has CTE, not certain on staging. I only just had my first appointment with him this week, and the plan is to continue with appointments biweekly moving forward. I did a cursory look on this and didn't see much information out there, period; medically or massage-related. I realized massage would not directly impact CTE, but at the same time, there are elements of massage that could possibly help with symptom management, like the happy hormones that are released and the parasympathetic influence. Being a former linebacker, my list of things to focus on body-wise is a pick and choose buffet, but I also want to try to have a better understanding of the implications of how CTE may come into play in my massage sessions. Of note, the possibility of sudden violent outbursts has not escaped my attention, and while it's not my focus, I'm still watching. 


0:03:03.6 RW: Now, I also work with clients who have PTSD and have for many years. I've never had an issue, but this also keeps me keenly aware of a client's mental state while they're in my care. The benefits and impact of massage on mental health is one of my points of indirect focus in my practice, and while CTE is physiological, there's definitely overlap. Wow, it is hard to overstate how much I love that last observation. I sing the, "the body and mind are not two different things," song all day long, and this is a great example of how we cannot separate our physical state from our mental and emotional state. 


0:03:48.3 RW: I'll also say, just for grins, that if I were ever to get back into practice, I would be fascinated to focus my practice on working with people with a history of central nervous system injury. It's a largely unexplored field, and I believe that massage therapy has a lot to offer here. So in this episode, I'm going to provide some information on brain injuries and on CTE in particular, and we'll talk about possibilities for massage therapy, but I will let you know from the start that while we can't reach inside someone's head to heal their brain, there's a lot that healthy touch can do to ease their experience. Let's start with some important definitions for these inter-related issues. We're going to define traumatic brain injury, concussion and post-concussion syndrome, and then CTE or Chronic Traumatic Encephalopathy. 


0:04:44.4 RW: Traumatic brain injury, according to e-medicine, is defined as an alteration in brain function caused by an external force leading to permanent or temporary impairment of cognitive, physical and psychosocial functions. So, that's our umbrella term, everything else we're talking about fits under this starting place. It is possible to have small-scale and multiple TBIs, traumatic brain injuries, without obvious concussions. A concussion is identified when a TBI causes the brain to impact or twist inside the cranium. So the brain can become bruised, neurons may be stretched. Sometimes, concussions are called mild concussions, but really, that's only in comparison to life-threatening injuries. Most people who have had concussions would describe them as anything but mild. About 15% of people who have a concussion develop a complication called post-concussion syndrome, where symptoms of dizziness and headache and sleeping problems, depressed mood, irritability, and problems with memory and concentration linger for weeks or months after a head injury. I did an article on post-concussion syndrome for Massage and Bodywork way back in 2014. 


0:06:08.3 RW: And I still remember how moved I was by my conversations with people who had been affected by this problem. And of course, we'll have a link to that article in our show notes. Chronic Traumatic Encephalopathy or CTE is a degenerative brain disease found in people with a history of repetitive brain trauma. Often, these repetitions of brain trauma may occur before the first trauma has fully healed or inflammation has subsided. We associate CTE mainly with military veterans, especially those involved with explosions, and athletes like football players and soccer players and boxers. It can affect anyone with a history of repetitive head impacts, whether those impacts caused a symptomatic concussion or not. This was first described in the early 1900s in boxers, and they called it "punch-drunk" syndrome, or more formally, dementia pugilistica. 


0:07:07.5 RW: In typical head injuries, tissues damage, inflammation develops, symptoms might persist, but ultimately, most people heal. But in CTE, something triggers self-propelling changes in the brain. It is progressive and it gets worse and worse over time. CTE affects Tau proteins, so we're gonna take a tiny tau protein tangent. Tau proteins act as scaffolding within neurons in the brain. I've also seen them described as our neurons' internal skeleton. They hold neurons in right relationship so that synapses can fire, neuro-transmitters can cross that synaptic cleft, messages can travel. If the tau proteins collapse or mis-function, then the neurons also collapse just like we would if our spine suddenly melted. Now, the synapses don't work because the axons and the dendrites aren't close enough. Post-synaptic neurons don't get stimulated and they wither. Actually, what we've just described here is part of the process that contributes to Alzheimer's disease. There's more in Alzheimer's, but the collapse of the tau proteins, our neurons' inner scaffolding, is a big factor. CTE is different. In CTE, the damage to tau proteins causes tau proteins to accumulate. Excessive tau deposits spread then throughout the brain, and instead of promoting neural function, tau then interferes with it. This is usually slow and it might take many years after the last head injury before symptoms emerge, but the progress keeps developing. 


0:08:58.4 RW: Sometimes, people have a more or less steady decline in function. For others, their situation seem stable for years, and then they enter a more rapid development of symptoms. When they appear, CTE signs and symptoms include short-term memory loss, confusion, impaired judgment, dementia. But this condition also affects mood and behavior. People with CTE also experience impulse control problems and aggression, mood swings, depression, paranoia and anxiety. CTE can't be definitively diagnosed in a living person. At this point, we can only identify it in posthumous studies of the brain. If this is of interest to you, the Concussion Legacy Foundation, Global Brain Bank accepts organ donations from people who believe that they had CTE or other brain injuries for the purposes of further study, and I think that's awesome. In the meantime, there are some specialized diagnostic criteria that can help neuro-pathologists to recognize patterns of CTE in living patients. CTE can't be reversed or treated, but individual symptoms like depression and anxiety can respond to medical and other kinds of therapy. People with CTE are encouraged to engage in excellent self-care and to focus on self-regulation to manage anxiety and stress, and to exercise, and to work on getting good quality sleep. 


0:10:34.1 RW: Can you see a role for massage therapy in these priorities? 'cause I can. Patients are also counseled to build a good support system, to develop consistent routines and to avoid activities that might stimulate impulsive behaviors like gambling, or using alcohol or addictive drugs. So where does all of this leave us with massage therapy? Well, actually, as long as everyone has realistic expectations, it leaves us in a pretty good place. I, like our contributor today, did a check for any data on massage therapy in the context of CTE, and I came up empty. However, if we change the search term to "concussion" or "traumatic brain injury," at least a couple of interesting studies come up. There is a really nice case report on massage for a person with concussion, and a review of interventions for patients with TBI that focus on mindfulness and overall health, and massage therapy is mentioned as part of a strategy toward achieving this. I wanna review what our contributors said about their work with this client. They said, "I realize massage would not directly impact CTE, but at the same time, there are elements of massage that could possibly help with symptom management, like the happy hormones that are released, and the parasympathetic influence. Being a former linebacker, my list of things to focus on body-wise is a pick-and-choose buffet, but I also wanna try to have a better understanding of the implications of how CTE may come into play in my massage sessions. 


0:12:14.2 RW: Of note, the possibility of sudden violent outbursts has not escaped my attention, and while it's not my main focus, I am aware. Now, I also work with clients who have PTSD, and have for many years. I've never had an issue there. But this keeps me keenly aware of a client's mental state while in my care. The benefits and impact of massage on mental health is one of my points of indirect focus in my practice, and while CTE is physiological, there's definitely overlap. Well, I appreciate this practitioner's concern about safety and sudden violent outbursts. My guess is that if an appropriate level of trust is established between the therapist and the client, and the client feels really safe, then this is unlikely to happen. In the meantime, working for those happy hormones or neurotransmitters is likely to offer at least some short-term relief. We know that massage therapy has a consistently positive impact for people with anxiety and depression, and what a gift to be able to bring our skills to someone so much in need. I don't have any suggestions for specific protocols to use or to avoid, because this would have to be based on the client's goals. But if his goals are to be able to relax and feel safe and respected and healthy, I'd say that with this massage therapist, he's on the right track. 


0:13:40.4 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 lowercase, @abmp.com. I can't wait to see what you send me, and I'll see you next time.


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