A contributor writes, “I said no to massage to a patient after fresh dialysis. When would it be OK to work on this person?”
Seems like a simple question. But it’s not. We know a fair amount about kidney disease and about dialysis. And here’s a surprise: The interface between massage therapy and people using dialysis has sparked a lot of conversation in research and medical circles.
What are people saying—and learning—about massage therapy for dialysis users? Better listen to this episode of I Have a Client Who . . .
Pocket Pathology: https://www.abmp.com/abmp-pocket-pathology-app
Çeçen, S. and Lafcı, D. (2021) ‘The effect of hand and foot massage on fatigue in hemodialysis patients: A randomized controlled trial’, Complementary Therapies in Clinical Practice, 43, p. 101344. Available at: https://doi.org/10.1016/j.ctcp.2021.101344.
Dialysis: Types, How It Works, Procedure & Side Effects (no date). Available at: https://my.clevelandclinic.org/health/treatments/14618-dialysis (Accessed: 6 September 2023).
Diane Mastnardo, B.S. et al. (2016) ‘Intradialytic Massage for Leg Cramps Among Hemodialysis Patients: a Pilot Randomized Controlled Trial’, International Journal of Therapeutic Massage & Bodywork: Research, Education, & Practice, 9(2), pp. 3–8. Available at: https://doi.org/10.3822/ijtmb.v9i2.305.
Habibzadeh, H. et al. (2020) ‘Effects of Foot Massage on Severity of Fatigue and Quality of Life in Hemodialysis Patients: A Randomized Controlled Trial’, International Journal of Community Based Nursing and Midwifery, 8(2), pp. 92–102. Available at: https://doi.org/10.30476/IJCBNM.2020.81662.0.
Hemodialysis - NIDDK (no date) National Institute of Diabetes and Digestive and Kidney Diseases. Available at: https://www.niddk.nih.gov/health-information/kidney-disease/kidney-failure/hemodialysis (Accessed: 6 September 2023).
I have a person who is on dialysis 3 times per week requesting massage therapy. We are taught that it is contraindicated in school. Is it safe for a person receiving dialysis to receive massage? (2014) National Kidney Foundation. Available at: https://www.kidney.org/blog/ask-doctor/i-have-person-who-dialysis-3-times-week-requesting-massage-therapy-we-are-taught-it (Accessed: 6 September 2023).
Kidney disease and massage - Ask Our Experts / Dr. John Agar, Nephrologist (2012a) Home Dialysis Central. Available at: https://forums.homedialysis.org/t/kidney-disease-and-massage/2745 (Accessed: 6 September 2023).
Kidney disease and massage - Ask Our Experts / Dr. John Agar, Nephrologist (2012b) Home Dialysis Central. Available at: https://forums.homedialysis.org/t/kidney-disease-and-massage/2745 (Accessed: 6 September 2023).
Kidney Disease Statistics for the United States - NIDDK (no date) National Institute of Diabetes and Digestive and Kidney Diseases. Available at: https://www.niddk.nih.gov/health-information/health-statistics/kidney-disease (Accessed: 6 September 2023).
Lai, M.-Y. et al. (2006) ‘Fever with acute renal failure due to body massage-induced rhabdomyolysis’, Nephrology Dialysis Transplantation, 21(1), pp. 233–234. Available at: https://doi.org/10.1093/ndt/gfi158.
Lazarus, E.R. et al. (2020) ‘The effects of an olive-oil massage on hemodialysis patients suffering from fatigue at a hemodialysis unit in southern India - a randomized controlled trial’, Journal of Complementary & Integrative Medicine, 18(2), pp. 397–403. Available at: https://doi.org/10.1515/jcim-2019-0338.
0:00:02.0 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?
0:01:00.8 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 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's story comes to me from a contributor who found me on Facebook and sent me this. They said, "Hello I have a question about a condition I can't find a lot of information on. I'm working at a chiropractor's office as a licensed massage therapist and dialysis came up. I said no to working on the person after fresh dialysis but when would it be okay to work on that person? Please get back to me when you can. Thank you."
0:02:17.7 RW: Oh, dear listeners. I had forgotten how much I love to talk about kidneys. In fact this became so intriguing and absorbing that I think I'm going to start with this podcast and turn it into a whole massage and bodywork article. The first thing I often do when I have a topic like this is to check on the etymology of the keywords and for dialysis I was not disappointed but I was confused. Here's what I found. It comes from Latin Dia for a part and Luan for set free which became over the years dialysis to which the etymology site applied this definition a statement of irreconcilable propositions.
0:03:11.2 RW: Wait. What? Irreconcilable propositions and dialysis. I don't get it. I read a little further and found that another way to interpret this idea of splitting something apart and setting something free is this the separation of particles in a liquid on the basis of differences in their ability to pass through a membrane. Huh. To separate and set free. Maybe like separating and removing wastes from the body. That makes sense. Oh, kidneys. How I love you. You do so much for us. You produce hormones that help us to regulate blood pressure and others that boost blood volume. You have one of my favorite structures called Glomeruli. Who can resist that name glomeruli where more blood enters than leaves and the leftover fluid is pulled into the nephron for processing and kidneys. You believe in the power of redundancy. We have about twice as many kidneys as we really need so if we have to we can be generous and give our extra one to someone else.
0:04:32.9 RW: When the kidneys are functioning well they do an amazing thing. Listeners, picture if you will a two liter bottle of the beverage of your choice. I have a two liter water bottle that I am now picturing with a couple of slices of cucumber in it and it's filled up to the brim and doesn't that look good? Are you with me? Now think about that and add 89 more of those. So you are now imagining 180 liters of fluid. You got it. That is how much fluid passes through the kidneys each and every day 180 liters of fluid, I hear you ask. But I don't even have 180 liters of fluid in me and I definitely don't pee out that much. Absolutely right but your kidneys are filtering your plasma every minute and it cycles through over and over again through the course of the day.
0:05:33.7 RW: Your plasma goes through these filters in the nephrons. Most of it gets sucked back into the bloodstream and only the materials that you don't need like salts and excess hormones and metabolic wastes and extra water are extracted out. That's what ends up traveling into the renal pelvis, down the ureters into the bladder and from there well I'll let you finish that story. When kidneys are damaged usually from chronic high blood pressure or poorly controlled diabetes or both then the speed of the movement of fluid from the circulatory system into the nephron. This is called the Glomerular Filtration Rate or GFR. Well when the kidneys are damaged the GFR slows way down. Hypertension and diabetes are the two most common contributors to slowing the GFR but a few other things can do this too like lupus and some other problems.
0:06:32.3 RW: Severe kidney damage can happen really quickly like with trauma or a blockage. That would be acute renal failure but for now we wanna concentrate on a much more common situation. Chronic kidney disease. Chronic kidney disease is progressive and in early stages it's usually silent but as function is lost then more and more symptoms develop and these symptoms can include things like fever and weakness and fatigue and muscle cramps and headache and poor appetite and rashes even changes in mental status and lots more because all of those waste products are accumulating in the bloodstream and getting into our organs but the onset of chronic kidney disease is so slow and gradual that a lot of people don't even know this is happening. Chronic kidney disease goes through five identified stages of severity eventually reaching ESRD which stands for End Stage Renal Disease and at this point the GFR, the Glomerular Filtration Rate has slowed down to about 10 to 15% of normal kidney function.
0:07:44.4 RW: So instead of cleaning up 180 liters of plasma now we're only cleaning up about 18 liters and this is not sustainable. All those waste products accumulate and damage organs including the brain and without treatment end stage renal failure is potentially fatal. However I have some good news we don't have a cure for kidney disease but we do have two treatments dialysis and kidney transplant and this is not an either or choice. Most people go on dialysis while they are waiting and hoping for a kidney transplant. There's lots more to say about renal disease but this is supposed to be a 15 minute podcast so I'm going to skip the absolutely fascinating and also infuriating statistics and move on to some more details about dialysis. This is an intervention for someone with failing kidneys End Stage Renal Disease. There are two main types of dialysis hemodialysis and peritoneal dialysis.
0:08:54.0 RW: Hemodialysis requires a preparatory surgery to connect and enlarge an artery and vein in the arm to allow for easy access and this structure is now called an anastomosis. Then when the person is hooked up a machine removes their blood, filters it through a dialyzer. This is a sort of an external artificial kidney that dialyzer is loaded up with dialysis fluid and then it returns the cleaned up blood back into the body and when this is done at a dialysis center it usually takes three to five hours and it has to be done three times a week without fail. The dialysis fluid that they use in these machines is not the same for everyone. It has to be customized to the patient's needs. Here's the thing though the process of dialysis takes a pretty big toll on the body and some patients have unpleasant side effects if their dialysis fluid isn't quite the right recipe for them and these side effects can include things like really painful menstrual cramps and high blood pressure and low blood pressure and high phosphate levels which can weaken bones and make your skin itch.
0:10:10.7 RW: Also chest pain and back pain and headaches and restless leg syndrome and absolutely debilitating fatigue. There is now a home version of hemodialysis which seems to work better and this can be done for shorter sessions but more often which is of course much more like how the kidneys work naturally and this seems to limit some of the worst side effects. Peritoneal dialysis uses the capillaries of the peritoneum to filter blood using a dialysis solution. To prepare for peritoneal dialysis. A person gets a permanent catheter inserted into their peritoneum and then during a session dialysis fluid flows through that catheter into the peritoneal cavity where it absorbs wastes and excess fluid from the body and this whole process takes about 60 to 90 minutes of having the abdomen all distended with this fluid. Then that fluid is drained out of the body and this has to happen four times a day although it can also be done during sleep. Dialysis whether it's hemodialysis or peritoneal dialysis is not a risk-free intervention.
0:11:25.1 RW: With hemodialysis, there might be infection or blockage or a blood clot in those affected blood vessels or the needle may become dislodged during treatment. With peritoneal dialysis, the person may develop skin infections or peritonitis or weakened abdominal muscles because of the distension and that might lead to a hernia. They also tend to absorb sugar from the dialysis fluid and then they gain weight. Still these complications are pretty manageable especially when they are compared to the option which is just crossing your fingers for a possible transplant very soon or dying of renal failure. The good news is that more than 50% of people on the waiting list for a kidney get one within five years of starting dialysis. Right now about 89,000 people are on the kidney waiting list and about 25,000 surgeries are performed each year.
0:12:24.7 RW: Okay then we have covered our wonderful kidneys and we've talked about kidney failure and we've talked about dialysis but where does massage fit?
0:12:36.7 RW: You might be surprised to learn that a lot of people have put some thought into that question. I was aware of a handful of research studies that I'll talk about in a minute but I was also surprised and pleased to stumble onto a long exchange from several years ago with a nephrologist who loves his weekly deep tissue massage who is answering some questions about the risks of massage even for people with advanced kidney disease. The link to this is in our show notes but I'll give you a spoiler alert. He felt that the benefits of massage generally outweighed the risks. Most of the research that I've seen on massage and dialysis have asked this question is there any benefit for patients in a dialysis unit to receive massage during their sessions?
0:13:28.3 RW: One study from India was quite large involving 200 people. That's really big for a massage study. Half of them got massaged to the back and lower legs at the beginning of their dialysis session and then hourly throughout their appointment and they did this for a total of eight weeks and their fatigue scores were notably lower than the control group. I couldn't access the whole paper for this so there are a lot of unknowns. I don't know if those fatigue scores were for that moment only or for their experience overall. We also don't know how long the massages were or the skill level of the practitioners but it does provide some interesting thoughts about massage and fatigue which is a big issue for this patient population.
0:14:12.4 RW: A similar study from Iran looked at foot massage on dialysis patients and it measured their fatigue and quality of life on standardized questionnaires. The patients got 20 minutes of foot massage three times a week when they were in their dialysis clinic.
0:14:28.5 RW: Data was collected eight weeks after the study concluded and I really like this because it allows us to see if those changes were consistent and if they stayed with the patient after that first immediate appointment. This study found clear differences in the massage groups compared to the controls. Not a surprise but great to see that kind of consistency. And another study asked a similar question and in a similar way this time in Turkey patients received hand and foot massage while undergoing dialysis and shocker, their fatigue scores improved. This study wanted to compare foot massage to hand massage and found virtually no difference between them. They were both associated with lower fatigue compared to the control group.
0:15:15.1 RW: The last study I looked at asked a different question which was whether massage during dialysis might help with painful leg cramps that a lot of dialysis patients report that happen between their sessions and it did.
0:15:30.6 RW: But do you notice a theme? All of these were done in hemodialysis clinics during the treatments and our contributor today described a client who was "After fresh dialysis" And who wanted massage and so what do we do with that? Well here are some questions I would recommend asking this client. Why are you on dialysis and how long has it been? Describe your activities. Can you exercise safely? What medications are you using to manage any other issues like kidney function or blood pressure and what are you hoping that massage can do for you?
0:16:11.6 RW: Now there are tons of more questions that would be good to ask but these can give us a running start to establish some good safety information and I'm gonna make up some answers. Here they are. I have been on dialysis for my diabetes for three years. I can't exercise a lot but I try to walk for at least half an hour a day and sometimes I lift these little weights with a video.
0:16:38.6 RW: I use a diuretic for blood pressure, insulin for diabetes. I'm on blood thinners and also cholesterol medications and I just feel so run down all the time. I'd love to feel a little more energy and maybe to not have such bad leg cramps at night.
0:16:56.7 RW: Now let's picture this person. She's 64 years old, she's overweight, she's trying to take good care of herself. She feels terrible and she thinks that massage might help. What are you gonna do? I have to say that I appreciate our contributors conservatism and they denied massage until they could get more information but I think there are things we can do even for someone fresh from dialysis to help with pain and anxiety and fatigue.
0:17:26.6 RW: It might not look like a regular massage but that's the beauty of our work. We need to avoid the catheter site for someone who's doing peritoneal dialysis and the place where they connected the artery and the vein for a person who's doing hemodialysis.
0:17:42.1 RW: Other than that we need to stay within their boundaries for how they can adjust to bodywork. Go slowly, work for relaxation and stress relief and above all monitor your results, get feedback so you can do even better next time.
0:17:59.0 RW: If you work with clients who are also dialysis patients I'd love to know about what you have experienced. Drop me a line at my website at ruthwerner.com and clue me in.
0:18:12.8 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 firstname.lastname@example.org. That's I have a client who, all one word, all lowercase at ABMp.com. I can't wait to see what you send me and I'll see you next time.