Stroke Rehab, Part 2

Coming Back

By Dietrich W. Miesler, MA, CMT

Originally published in Massage & Bodywork magazine, June/July 2000.

Basis for Massage Therapy

The question comes up occasionally — What makes massage so special that we want to put it into patient care? The skeptic talks of placebo effect, while the massage junkie talks of the power of touch. Sometimes we ourselves are surprised at our results. We look at our hands and note they are remarkable tools, but we know that so are everyone else’s.

I, for one, find that it is not our hands, nor our touch, that are magic. The magician is the body. What it really comes down to in this work is that we are affecting the nervous system. The muscles can’t do a thing without the myriad of nerves that are present in every cubic centimeter of muscle flesh. They can’t relax, tense or move. The body is built for self-maintenance, and an especially compromised body is your greatest helper as it will pick up and utilize whatever you are doing to help it stay alive.

What the body is searching for is homeostasis. The greatest contributor to maintenance of, or the acquisition of, homeostasis is blood circulation. Circulating blood is the great communicator and supplier of essentials, and as long as blood is freely circulating, there is healing going on. Blood provides oxygen, picks up nutrients, carries orders from the hormonal glands to anywhere in the body within seconds, provides temperature control, picks up debris from cell repair and replacement, carries the debris to the kidneys where it is sorted into recyclables and garbage, and it stops by at the liver to pick up bile, as well as fat and protein molecules. While at the liver, it also drops off substances for chemical analysis and detoxification. It takes care of “disinfection” by means of the white blood cells which scavenge around. Massage with our hands provides 10 times as much oxygen to the massaged areas as the body would receive passively in 15 minutes.1

But there is something else inherent in the circulation system — its ability to actively influence the amount of blood sent, especially into the peripheral microcirculation. Research by Furchgott and Zawadsky2 proved conclusively that there is a substance released by the endothelium of both venules and arterioles, which they called “endothelium derived relaxing factor” (EDRF), later identified as Nitric Oxide (NO). NO has been a known powerful vasodilator, but it was not expected to be produced right there in the blood vessels. That the release of NO is triggered by shear stress (i.e. muscle contraction) emphasizes the function of the EDRF complex relative to the control of blood flow in the moving body. And into this super complicated system we intrude with our two hands, trying to set things right.

From the first day I took on massage seriously, and by observing and thinking about what I was doing, I came up with some small refinements of the attitude with which I was working the body. The following (partial) list was developed over 25 years of massage work:

• It is not necessary to work longer than 30 minutes with a client at one session.
• The key to a good, relaxing massage is proper positioning.
• Unless a muscle is completely relaxed, massage could be counterproductive.
• Small talk during massage destroys therapeutic concentration.
• When you work on a specific problem, stay with the same sequence of movements.
• There is no health condition I ever came across that justified real deep pressure massage.
• If the occasional patient requests a firmer massage, tell him that the purpose of your work is to flood his muscle system with blood. If you exert too much pressure on his muscles, the reaction to your harder strokes will hinder flow, leading to the opposite result.
• If you find a muscle that doesn’t yield to gentle moves, you have the proof that the muscle was not relaxed properly.
• Elbows have no place in massage. There is nothing you cannot do better with your hands.
• The same goes for the use of the forearm for effleurage.

Working the Patient with Stroke History

Every book on stroke rehabilitation tells you to start work immediately when the stroke patient is stabilized; in most cases that is 48 hours. But unless you are associated with a hospital and usually work within a physical therapy department, you will never have a chance to work with a stroke patient that early. Therefore, we will discuss how to work with a patient who had the stroke anywhere from a few months to years ago. With some experience in massage, you will be able to interpolate what to do, should you get a chance to work with a more recent stroke patient.

Before you begin to work with a stroke patient, you first should do a little meditation. Try to fathom what a devastating experience it must be for the client to suddenly lose consciousness and after anywhere from five minutes to several days, wake up and be unable to move or speak anymore. Imagine feeling like your head is going to burst, and if you call for help, all you can produce is a gurgling sound. Imagine being unable to move a whole side of your body — to feel like you have been kidnapped, bound and gagged, and to feel a terrible fear creeping up as you have no idea what happened to you.

Reports tell us that this initial awakening is an event engraved indelibly in the patient’s memory. If you’re dealing with a client whose memories are now several months or years old, you will be dealing with a person who has somehow adjusted to the present state of affairs. Now all you have to do is find out if you are dealing with a fighter or a victim. Are you working with someone ready to put up a fight against his handicap, or with someone who feels totally defeated and is willing to live as a slave to his handicap?

This is not necessarily the person’s choice, because sometimes in a stroke there is brain impairment that runs the person’s life henceforth. Occasionally, you may even run across a person who is belligerent and who, in anger, strikes out with his one movable arm at anyone who comes near. Do not try to hide your compassion; it will be the key to the patient’s trust. And don’t let anyone warn you not to get too close with a client. If you are not accepted by the patient as a friend (and confidant) your work will be twice as hard and half as effective.

Be careful, however, that your visits don’t become social calls rather than healing interventions. Try to limit your conversations to his conditions and what you want to do about it, with his help. Talk with the social worker about your observations, but do not share anything that was told to you in confidence. Your responsibility is to develop an individualized treatment plan. For instance, determine with your patient what he wants to emphasize (e.g. further his walking ability). Write out your intentions and discuss them with the physician or with the physical therapist. For this example, you can be successful with leg massages and Range of Motion (ROM) exercises, both of which will be discussed in-depth next time. This will be even more effective if you can make arrangements through the charge nurse to have a certified nursing assistant (CNA) ready to walk the patient right after the massage. Don’t forget to chart the patient’s activities and do so as soon as you notice any progress. Talk about it and demonstrate it on a graphic chart, because nothing is as effective in keeping your client’s spirits high as well-deserved praise.

The other major project that is within your domain is working on his arm, which probably will have been neglected because there is just not enough time for the nursing staff to do all these things. You can combine this nicely with a shoulder and neck massage. Female patients, especially, show little progress with their clipped wing without a therapist to help. The fact that the arm is out of commission is only part of the story. The bad part is that the whole shoulder portion including the spine of the neck is thrown off and may lead to scoliosis of the upper spinal column. That’s the reason why you should work on hand, arm and shoulders, even with year-old strokes.

Of course, when working with a paralyzed arm you have to go about it very systematically by always starting at the hand, and always using the same sequence, even if you plan to work many months just on the arm. Relaxing an arm that is not ossified in the joints can take a year-plus to finally end up with relaxed muscles. In the case of an ossified joint, there is not much improvement you can expect.

Concluding Remarks

Dealing with stroke rehabilitation in the manner that has been explained in this article really moves us from the field of wellness massage to the area of medical massage. This distinction will alter most aspects of our work far beyond the mere terminological changes of “client” to “patient,” The distinction makes us more responsible for understanding the implications of the diseases we are faced with in our clientele. Therefore, first and foremost there is the need to increase our knowledge base.

Our involvement with, and development of, special massage techniques for the elderly population indeed gives Day-Break graduates a clear edge over many therapists. However, the day will come when obodyworkers’ involvement with geriatric massage alone may not be enough to pass an as-yet-unestablished certification exam in medical geriatric massage. Most areas of recognized complementary therapy are moving toward proficiency standards, like national certification examinations, so take note. Certification also moves the field closer to recognition of our contribution to the clients’ overall rehabilitation effort and thus to much more adequate insurance reimbursement.

Superficially you may disregard these concerns, but consider that the Medical Massage Office Manual3 reports that half of all the money paid for massage last year in the United States was paid for by insurance carriers, leaving the rest of the payments coming out of patients’ pockets. This is because only 3% of massage therapists billed insurance carriers. According to the authors, quite a few of the therapists within that 3 percent are generating substantial revenues. Knowledge, consistency and initiative can go a long way toward pushing therapeutic medical massage forward and into the circle of recognized, valid interventions. Insurance companies are quickly realizing the advantages of many complementary therapies over more invasive, expensive procedures. The time is ripe to tap into that market and make massage therapy for the patient with stroke an established and preferred adjunct therapy of choice.