Ep 333 – Shingles Redux: “I Have a Client Who . . .” Pathology Conversations with Ruth Werner

An image of a person with a shingles outbreak on their lower back.

In our Third Annual Shingles Episode, we consider a client who developed shingles soon after receiving massage. Is it possible that the massage caused it? And what are the safety guidelines about working with someone during a shingles outbreak?

It turns out this is all more complex than it sounds, and the decisions here require some nuance. Listen to “I Have a Client Who . . .” for more!

Resources: 

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

Episode 20:

https://www.abmp.com/podcasts/ep-20-undiagnosed-rash-what-do-you-think-it-i-have-client-who-ruth-werner

Episode 118:

https://www.abmp.com/podcasts/ep-118-shingles-how-long-do-we-wait-i-have-client-who-pathology-conversations-ruth-werner

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.

Sponsors: 

 

Massage Mentor Institute

In 2019, Diane Matkowski, aka the Massage Mentor, began a closed Facebook page for hosting discussions with industry leaders. These interviews gave her an idea for The Massage Mentor Institute and Jam Series workshops.

The goal was to create various continuing education classes offered in one spot. The Institute is a space for massage therapists to learn different approaches and philosophies of bodywork and business classes. It’s also home to the Shoulder, Hip, Neck, and Back Jam workshops.

We believe that no one technique works for every human being. Our goal is to help you find your path. We have selected teachers we trust, admire, and believe will help you grow as a licensed massage therapist.

Website: themassagementorinstitute.com

Facebook Group: facebook.com/themassagementor

Instagram: @massagementorinstitute

Full Transcript: 

0:00:01.4 Ruth Werner: Hello, I Have a Client Who listeners, Ruth Werner here, and I'm so excited to let you know that my library of online self-paced continuing education courses has just expanded. I now have a two-hour ethics course called, A doctor's note is not good enough, and what is better. This NCBTMB approved course goes into why a doctor's permission or approval or even a prescription doesn't provide the legal or safety protection you might think it does. Then we look at how to start useful conversations with healthcare providers that will actually get us to safe and effective massage for our clients with complex conditions. Visit my website at ruthwerner.com for more information and to register for, A doctor's note is not good enough and what is better?

0:00:52.1 Speaker 2: Introducing Back Jam. Held online the first four Mondays in May 2023 and hosted by the Massage Mentor Institute. This is the fourth event in a series of workshops focused on a single region of the body. We've gathered the following industry leaders, Til Luchau, James Waslaski, Tom Myers, Diane Lee, Paul Kelly, Sue Hitchman, Whitney Lowe, Aubrey and Allison Gowing. Allison Denny, Judith Aston. Benny Vaughn, Heath and Nichole Reed and Ruth Werner. Sign up for the Back Jam, sponsored by ABMP at themassagementorinstitute.com.

[music]

0:01:43.3 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.

0:01:57.0 RW: I'm Ruth Warner, 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. In today's episode, I'm going to revisit a topic I've addressed a couple of times in I Have a Client Who, shingles. Interestingly, this has been happening about once a year, so here is our third annual shingles episode.

0:02:45.8 RW: But this case is really extraordinary, it comes from a seasoned massage therapist who I've had the pleasure of knowing for many years, and it goes like this. I have a client who gets severe shingles outbreaks a lot. I saw her two weeks ago and she was feeling overjoyed that she hadn't had an outbreak in months, and then sadly, she came back a week later with an excruciatingly painful outbreak. I gave her a really light touch, with holds. Afterwards, I listened to your podcast on shingles, and then I thought I probably shouldn't have treated her at all on that second visit. I also read, it's possible a massage could trigger an outbreak, particularly a heavy pressure massage. Because of her age and the condition of her muscles, I never do deep tissue work or use heavy pressure with this client. But I do wonder, if that first massage two weeks ago, could have stimulated the shingles' nerve root.

0:03:44.7 RW: If you have a minute, I would so much appreciate knowing if you've researched whether massage can trigger shingles and your opinion of working with a client like this. When I think back over the first massage, I wonder if there were any signs that the shingles virus was brewing under the surface. She was getting ready to go on a vacation and was excited about the possibility of taking a trip without a shingles outbreak. Since she had experienced shingles on a trip to Europe in the past, suffered on the plane, couldn't enjoy the sightseeing, very difficult as you might imagine.

0:04:16.1 RW: It didn't cross my mind that she could end up with shingles after all. I feel terrible that it could have been from the massage. Well, I replied, I just did a quick scan of massage trigger shingles and found a couple of hypotheticals, but nothing backed with any kind of science or rationale. I'm so sorry this happened for your client, how disappointing and how painful and infuriating and all the things for her. But assuming she didn't leave you in greater stress than when she showed up, it's hard to make a case that you had anything to do with it.

0:04:51.0 RW: Shingles doesn't spread through the bloodstream or through touch on intact skin, and your gentle touch with holds was surely no more challenging to her than her normal activities of daily living. With your permission, I'd love to use this in another shingles episode, would that be okay with you? And the therapist sent back to me, yes please. She said she had started feeling tingling around her clavicle and then the outbreak happened a while later. I wonder if the virus got activated in the brachial plexus. I knew someone who had genital herpes who said outbreaks would start in later years with almost debilitating back pain, and it had been almost unnoticeable in that person's younger years.

0:05:31.5 RW: How much we don't know about how viruses behave, they can be mind-boggling. And that was the end of our correspondence. Well, that's absolutely true, about viruses being mind-boggling. Especially for viruses in the herpes family, like Varicella Zoster, the causative agent for both chicken pox and shingles. Herpesviridae, which include Varicella and Herpes simplex and Epstein-Barr virus, and Cytomegalovirus and a few more, often show patterns in how they affect humans. But then, they like to break all the rules, like you're only supposed to get chicken pox once. That's what happens for most people. And then if you're very unlucky, you might get shingles later in life, but really only once. But how many of us have had or know people who have had chicken pox multiple times, and much worse, shingles multiple times. It's not the norm, but it happens. And it's miserable.

0:06:28.9 RW: I searched pubmed.gov and Google Scholar, for any data on a possible causative relationship between massage therapy and a reactivation of Varicella Zoster, and I didn't find anything. Not even any reports of adverse events that might suggest massage caused an outbreak of shingles. A more general Google search with these terms, yielded a handful of sources that suggest the possibility that massage might trigger shingles under certain circumstances, but as I replied to our contributor, none of them are presented with any credible data or rationales. Maybe you could make an argument that, very deep tissue work that is painful and stress-inducing might be so traumatizing that the virus might reactivate?

0:07:14.7 RW: I'm still extremely skeptical. Let's remember that when a person is infected with Varicella Zoster, usually in the form of chicken pox, and then they recover, well, that virus is not fully eradicated, instead, it goes into hiding. In some level of a dorsal root ganglion or maybe the trigeminal ganglion, and that person's circulating antibodies keep that virus colony quiet, hopefully, for the rest of their life. But, if their immune system gets stretched a little thin, maybe from age or stress or other diseases. Or maybe they just didn't have a serious enough case in the first place to develop a strong set of B cells that should continue to produce antibodies, in any situation, it can happen.

0:08:00.4 RW: That that colony of virus might someday reactivate and cause shingles. And while chicken pox is usually presented with blisters all over the body, with shingles instead we get a pattern of extremely painful blisters that follow the line of the nerve that was invaded. So this might go down the buttock and then down the leg, or around the rib cage or up over the face, each of these shows the dermatome, supplied by the nerve ganglion where the colony of virus has been hiding.

0:08:29.4 RW: It's almost never bilateral, and if it happens repeatedly, it will probably happen in the same area, which indicates where the virus has been hiding. Unless the person is harboring multiple colonies of the virus, and then they might have it in different areas. It can happen, and this was the case in last years, I Have a Client Who episode on shingles. That the virus can reactivate and cause a lot of pain along a specific dermatome, but no rash appears on the surface of the skin, there is no blisters and nothing to see.

0:09:04.0 RW: And in this situation, it might be mistaken for a heart attack or a disc injury, it's that painful. The person in today's story, must have her colony in a dorsal root ganglion somewhere between T1 and C5, because her outbreaks affect her arm. To recap, our contributor said, I saw her two weeks ago and she was feeling overjoyed that she hadn't had an outbreak in months. Then sadly, she came back a week later with an excruciatingly painful outbreak, and I gave her really light touch with holds. I also read that it's possible a massage could trigger an outbreak, particularly a heavy pressure massage. Because of her age and the condition of her muscles, I never do deep tissue work or use heavy pressure with this client.

0:09:47.2 RW: But I do wonder, if that first massage two weeks ago could have stimulated the shingles nerve root. So this massage therapist wants to know if somehow their work at that first session might have been responsible for this outbreak. And wonders if maybe they should have delayed that second session. And as I said in my reply, I just can't imagine how a massage that isn't forceful or stress-inducing might trigger a shingles outbreak after the first session. And while delaying the second session might have been a good idea, just in terms of client comfort, giving light touch and gentle holds to a person who's in pain, just sounds lovely to me.

0:10:24.4 RW: At this point, you might be asking, but hey, wait a minute, what about communicability? Because this is catching, right? And the answer is yes. Sort of, but for most people who have healthy immune systems, we have already been exposed to this virus one way or another, and our circulating antibodies provide us with protection against a new infection. There are a couple of ways exposure to shingles can cause a problem for someone else, first if the someone else is what we call Varicella naive. If they've never been exposed to the virus, either as an infection or in the context of a chicken pox vaccine, then yes.

0:11:05.1 RW: Exposure to those fluid filled blisters might prompt them to develop either chicken pox or shingles. And it is really important to respect that. Alternatively, if someone else has had Varicella, but they're immune compromised, so their circulating antibodies are just not up to the task. Then another new exposure might, might prompt a new outbreak. I have to wonder, if the client in today's story might be immune-compromised in some really important ways, for her to have these repeating episodes of shingles. I've heard of such things, in people who are under treatment for cancer or who need immune suppressant drugs for autoimmune disease, for instance.

0:11:51.9 RW: And I feel just terrible for her, whatever her situation is, her propensity for repeated shingles outbreaks, suggest some serious problems in her foundational health. But I do wanna reassure this massage therapist and anyone else listening that the chance of a normal gentle relaxing massage triggering a shingles episode, is in my opinion, slim to none. The physiology just doesn't stack up that way, and if you have a chance to offer soothing pain-free touch to someone who is in the midst of a shingles outbreak, well, consider the status of your own immune system and make your choice on that basis. Generally, I think it's a good idea to just delay until the blisters are healed and the symptoms have cleared, but I can see circumstances where like in today's story, the offer of caring touch might be reasonable to someone who's in a lot of pain.

0:12:46.8 RW: This is my third episode on shingles and I still haven't had... And I Have a Client Who story on post-herpetic neuralgia, which is a pretty common complication. Where are you post herpetic neuralgia story? I hope to hear from you soon.

0:13:03.9 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, 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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