Two clients. Two left legs that are swollen and hot. Two surprising outcomes. We explore deep vein thrombosis, pulmonary embolism, and venous thromboembolism, and even take a quick peek at aortic aneurysm. Lots of long words in this one, and lots of opinions from me.
Sefton, J. M., Yarar, C., Berry, J. W., and Pascoe, D. D. (2010). “Therapeutic Massage of the Neck and Shoulders Produces Changes in Peripheral Blood Flow When Assessed with Dynamic Infrared Thermography.” Journal of Alternative and Complementary Medicine (New York, N.Y.), 16, no. 7, 723–32. https://doi.org/10.1089/acm.2009.0441.
Shoemaker, J. K., Tiidus, P. M., and Mader, R. (1997). “Failure of Manual Massage to Alter Limb Blood Flow: Measures by Doppler Ultrasound.” Medicine and Science in Sports and Exercise, 29, no. 5, 610–14. https://doi.org/10.1097/00005768-199705000-00004.
Werner, Ruth. “‘Low Risk’ Does Not Equal ‘No Risk’”: An Overview of Reports of Adverse Events.” Massage & Bodywork magazine, May/June 2020. www.massageandbodyworkdigital.com/i/1234356-may-june-2020/32.
Additional articles by Ruth Werner:
00:00 Speaker 1: 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 groundbreaking 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.
01:25 RW: For this episode, I have two terrific stories from a massage therapist in Washington, they conclude with an interesting twist. Certainly one I didn't anticipate. Here's how it goes. "I have a client who is an 85-year-old male with type 2 diabetes. He comes in for a monthly maintenance massage, other than type 2, he's a picture of health and a person who exercises every day, he does have some neuropathy in his feet and has had carpal tunnel surgery in both wrists, his main issues that I've treated him for for years are trapezius pain and tension and lower back pain that he has successfully managed for 35 years by taking frequent breaks when driving, taking a five-minute dip in his hot tub every evening for 30 years or more, and receiving regular chiropractic and massage. In a session two years ago, I was working on him and his lower left leg was visibly swollen and different in size, there was some heat in the area, but no redness."
02:30 RW: "I spoke with him about whether he had noticed this or if he had any noticeable pain in the area, and he answered no, to both questions. My obvious concern was DVT, and I made the recommendation that he see his doctor and request imaging to rule out a clot as soon as possible, he thanked me and agreed to make the appointment. I did not end the session, but focused on the upper body and the hips for the remaining time in the treatment, I had another client with a similar swollen warm lower left leg, this time with some redness, this was a 76-year-old male with a diagnosed thoracic aneurysm, the aneurysm was being monitored by a pulmonologist in a wait and see way, and I had in his file a current written permission for massage therapy from his doctor."
03:19 RW: "This man was less healthy and more annoyed in his response to my request that he see his regular doctor and get a diagnosis. I ended the treatment by avoiding his legs and focusing on his upper body and upper extremity pain." Before we continue, I wanna thank this massage therapist for sharing these stories, there are some really good things to unpack here, and I wanna invite you to share your, "I have a client who... ", stories too, you can do that by sending them to me at, firstname.lastname@example.org, that's, Ihaveaclientwho, all one word, all lowercase at abmp.com, and I will look forward to seeing what you send me. Isn't it interesting that this therapist noticed this relatively subtle sign in the lower left legs of two of her older male clients, and she made a good choice in bringing it to their attention and requesting that they get some medical attention for this situation. We aren't told, but I hope the way she phrased this was that they should do that before they come back for another massage.
04:33 RW: I do wanna speak to one issue that she brought up in relation to the second client, the one with the thoracic aneurysm, as she says, this client was generally less healthy and he was under ongoing observation because of his thoracic aortic aneurysm, and that in itself is not unusual, it's possible to have a widening of the aorta that's pretty stable. In this situation, treating it with a stent or some other kind of intervention would probably be riskier than just letting it be. So with this type of aortic aneurysm the standard treatment is to watch and wait, when or if the widening gets larger than a certain level, that's when it becomes clear that the benefits of intervention will outweigh the risks. And she also had in her file and I'll quote, "current written permission for massage therapy from his doctor". I have many opinions about this. I think it's great that there was a conversation at some point between this massage therapist and the client and the client's doctor, so everyone is informed about this client's challenged health and his desire to receive massage.
05:43 RW: However, and if you spend any time with me in this podcast or in classes or in other places, you will know what I'm about to say next, consulting with a healthcare team about safety is appropriate and professional, and I'm 100% in favor. Requiring permission to do our work, that's not the same thing. It is not a doctor's job to know what the risks are related to our massage therapy, and if God forbid, a massage therapist makes a mistake and causes serious harm to a client, a doctor's permission will not protect them from litigation. Now, I am not saying that this massage therapist was being inappropriate, not at all. Clearly, she had invested some time and effort in making sure that what she was doing was safe for this client, the permission that she had from the client's primary care physician was very likely the result of a consultation that helped her determine safety parameters, and clearly she's working carefully enough to notice when one of his legs is warm and red and puffy.
06:54 RW: I just don't want to promote the idea that getting a doctor's permission makes massage therapy safer. Consulting with the client's doctor or healthcare team definitely can help us to be safer as we try to make clinical decisions that will maximize whatever benefits we have to offer while minimizing the risks, but we can't rely on someone else's permission to be sure that our work is safe, that's our job. So I thought we might take a little time to discuss the relationship between massage therapy and the risk of DVT and PE or pulmonary embolism.
07:37 RW: Just a really quick review, DVT stands for Deep vein thrombosis. This is a situation where a clot develops in a deep vein. We usually see this somewhere in the leg, but DVTs have also been seen in the pelvis, and clots can also develop in the veins of the arms, DVT is often unilateral, but not always, when it's in the leg, it might be obvious with pain and redness and heat and distal swelling that follow some kind of trauma. My mother had this, she had cracked her tibia and her leg swelled up like a tree trunk, by the time we got her to a doctor, she had a blood clot that ran from her ankle to her thigh. But sometimes those DVT signs are really subtle, the trauma might seem really mild, like getting kicked during soccer practice or DVT might follow a period of inactivity rather than a trauma, and that's why this is sometimes called coach class syndrome, and if a fragment from whatever is happening in the vein breaks loose and travel, those fragments will keep moving through the cardiovascular system until they hit a blood vessel that is too narrow to let them pass. Trace that pathway up from the lower leg, up the thigh into the pelvis and into the vena cava, all those veins are just getting bigger and bigger.
09:04 RW: Now, from the vena cava, those clot fragments can enter the right atrium of the heart, anything to stop them there, nope, lots of room, and then they get pushed into the right ventricle, still lots of room and out into the spacious pulmonary arteries that will jet them toward the lungs, whack, that's where the vessels start getting small again, and when these clot fragments reach branches of the pulmonary arteries that are too narrow to let them through, they will stop and all the tissue downstream is blocked, and this is a pulmonary embolism. Altogether, a DVT and a PE may be called a VTE, Venous thromboembolism, and this situation causes anywhere from 60-100,000 deaths each year in this country. The only situation in which a blood clot from a vein might not travel this route to lodge in the lungs is if the person has a hole in the septum of their heart, a Patent foramen ovale, and this is the topic of another, "I have a client who... ", podcast.
10:18 RW: To return to our story, as you heard, after this massage therapist had identified the possibility of something odd happening in both of these clients legs, she continued their appointments, but worked only on the upper part of the body. And I get this question a lot, Is that safe? If someone has a blood clot in a vein in their leg, and if massage boosts circulation the way we've been taught it does, I remember hearing that massage boosts circulation by 300%, well then, wouldn't doing massage on the back or the arms or the chest, run the risk of helping that clot in the leg to fragment and travel? And the answer is, we don't know for sure. Done with a great deal of care, maybe not, it's hard to imagine an ethical research study to test this question, plus which all kinds of things might cause clots to break into fragments, climbing the stairs, taking a hot shower, anything that requires adaptive responses could contribute to this risk.
11:27 RW: However, I regularly scan the literature for case reports about massage-related adverse events, these are situations where it has been reasonably demonstrated that something bad happened because of a massage. I also frequently serve as a consultant or expert witness in litigations where a massage therapist has been accused of hurting a client. So I've seen some of this in action, not every adverse event makes it into the medical literature or into a lawsuit, obviously, but some do. And in fact, my pathology perspectives article in the May-June edition of Massage & Bodywork magazine lists an updated review of documented adverse events. I'll put a link to that in the show notes. And in that context, we have seen the potential for DVT complicating it into a pulmonary embolism, but so far we've only seen that when massage has been given directly to the part of the body with the blood clot.
12:28 RW: By contrast, there is some data that suggests the effect massage has on circulation, and I use that term carefully, is probably not as much as we think. Circulation can mean many things. Can't it? It can refer to arterial flow or Venous flow or lymphatic flow, it can suggest systemic consequences or only local ones, it can be about superficial circulation or about deep circulation, it's not hard to demonstrate that massage has impact on superficial local circulation. We can see that just through changes in skin temperature, right, but when we try to look for changes in the deeper blood vessels, Oh, that's not clear at all. Doppler ultrasound does not support the hypothesis that massage boosts arterial circulation deep in the muscles.
13:21 RW: But here's another twist. Most of this research has been done on healthy people, of course, and the way the body adapts and compensates might be really different for people who are dealing with blood clotting risks, and this is one of the reasons I've been giving advice to be super conservative for clients who are recovering from COVID-19, for instance, who might be at risk for coagulopathy. But, let's go back to our two gentleman whose massage therapist asked them to get checked. Remember the first one? 85 years old in general, good health, but with diabetes, he had visible swelling and palpable heat in one leg but no redness, the other one, 76 years old with an aortic aneurysm, had swelling, heat and redness in one leg, both went on their massage therapists advice to be checked for deep vein thrombosis to their primary care physicians. Both were negative. Phew. Does that mean their massage therapist overreacted? Nope. I didn't get from these stories what kind of time frames passed between when the massage happened and when these clients visited their doctors, so it's possible that if clots were present, they dissolved on their own, that happens, or maybe it wasn't clots at all, maybe it was something else that cleared up. Regardless, this massage therapist demonstrated really excellent client care by getting more information before she put these people at any further risk.
14:54 RW: I can't tell you how many, I have a client, whose stories I've heard where the massage therapist did indeed identify the possibility of a DVT that was confirmed later and they may have saved those clients lives. We are on the front lines for our clients in many ways, having to do with recognizing challenges to their health, and when our caution turns out not to be necessary, well, that's just good news for everyone, our clients, and for us.
15:24 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 too. 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.
15:53 RW: Anatomy Trains is excited to announce a new on-demand video course with Tom Myers coming soon, deeper ground restoration and vitality for the female pelvis, reach your deeper ground of embodied awareness and strategic confidence with this four-hour tour of the female pelvis, including its key points and unique challenges. Course highlights include hands-on palpation certainty and technique review for the major muscle groups, assessments and techniques for posterior and anterior pelvic floor, so as complex and diaphragm, common perinatal bio-mechanical issues explained and much more, sign up for the Anatomy Trains newsletter at Anatomytrains.com to be notified when the course is available.