Conditions

Interview questions:

1. When was the hypertension diagnosed?

2. What tx was given? Any lifestyle change encouraged, such as dieting, exercise, smoking cessation? 

3. What medication prescribed? Which drug? Does the client take the medication? When was the last time the client took medication? Is BP stable now?

4. Any lifestyle restriction imporsed by physician? hot bath, reduced vigourous exercise, change of sleeping position ( avoid sleeping on stomach or lying flat on back)?

5. Is this your first massage? Does your physician know you are receiving massage? Otherwise, what's your response to previous massage?

6. Is there any history of: heart disease, treatment of angioplasty or bypass surgery, arteriosclerosis, kidney disorder, myocardial infarction (heart failure), angina pectoris, left ventricular hypertrophy, transient ischemic attacks and strokes, familial hyperlipidemia, diabetes, metabolic disorders ( hyperthyroidism or adrenal tumours)

Refer out if:1) change in BP from the patient's normal range; 2) BP is measured twice with value 140-180 (SP) or 90-105(DP)

Contraindications

1. severe hypertension with complicated pathology, or moderate hypertension but uncompliiant with medication, contact physician to determine i) appropriateness and safety; ii) tx modification.

2. increased SNS firing increases BP.  NO prolonged painful tenchiniques

3. TP compression or stripping, fascial techniques to limited area interpersed with gentle soothing techniques. 

4. vigorous tapotement - NO cupping, hacking and pounding 

5. Neck and associated vasculature (carotid artery), prolonged neck rotation =>occlusion of blood flow. => NO bilateral Tx especially deep techniques on SCM.

6. NO return of large volume of venous and lymphatic fluid to the heart. Replace full-body application of repetitive long and broad strokes with short semgental strokes. 

7. NO repetitive, passive, large limb movements in mid and full ranges.

8. NO prolonged elevation of legs above heart level. 

9. NO full body lymphatic drainage.

10. NO full-body hydrotherapy or prolonged heat application over back or pectoral region.

11. NO hypertensive essential oils.

Massage Treatment

1. Mild and stable, compliant patient does NOT need modification. Therapist remain vigilant for any sign of distress.

2. Moderate and stable, reduce Tx time in prone, elevate upper body in supine, painful Tx be performed over a series of steps, limited use of long strokes.

3. Positioning: 

   1. ask for sleeping position or any other restrictions given by physician. 

   2. if patient is able to sleep on stomach, prone is ok

   3. reduce prone time as pressure on abdominal aorta

   4. sidelying is ok, R>L because of stress on heart, reduce left sidelying

   5. supine in semi-seated with pillow supporting trunk to reduce stress on cardiovascular system

   6. seated for moderate to severe hypertension

4. soothing and less vigorous techniques, DB => reduce SNS firing => reduce BP

5. moderate or complicating cardiovascular condition => start from limb with short & segmental strokes

6. watch for: increased heart rate, dizziness, respiratory rate, shallow breathing, sweating, fascial flushing. => switch to semi-seated, use segmental techniques on limbs, or put in seated position until symtoms pass.

Self-care

1. relaxation response technique = 2x 20min meditation, comfortably positioned, slow, easy breath, DB/progressive relaxation

2. moderate aerobic exercise

3. diet, cessation of smoking

Fibromyalgia — a non articular (affecting soft tissues such as muscles and connective tissues rather than joints), painful, rheumatic condition of at least 3 months duration. The disease is characterized by widespread muscular achiness and specifically the palpation of tender points at 11 of 18 prescribed locations on the body. Fibromyalgia is accompanied by fatigue, sleep, memory and mood issues. Researchers believe that fibromyalgia amplifies painful sensations by affecting the way the patient’s brain processes pain signals. Fibromyalgia affects 2-6% of the population. 

1. Diagnosing Fibromyalgia - 18 TENDER POINTS ( bilateral: 9 x 2 )

There are 18 symmetrical tender points of which at least 11 need to be found on examination to determine fibromyalgia. This distinguishes fibromyalgia from chronic fatigue syndrome, myofascial pain syndrome, arthritis, lupus.

POSTERIOR:

1.) Suboccipital mm insertion, inferior to occiput
2.) Upper trapz, midpoint of upper border
3.) Supraspinatus origin, medial near spine of scapula ( by the upper angle of scapula)
4.) Anterior glute medius
5.) 2 cm posterior to greater trochanter

ANTERIOR:

6. ) Anterior aspect of c5-c7
7.) Rib 2 at costochondral junction (sternum)
8.) Extensor digitorum, 2 cm. distal to lateral epicondyle
9.) Knee- medial collateral ligament

2.  Causes of Fibromyalgia

l  Immune abnormalities

l  Genetic predisposition

l  Fibromyalgia is Triggered / Aggravated by:

• Overexertion

• Lack of exercise

• Stress

• Anxiety

• Depression

• Lack of sleep / too much sleep

• Trauma

• Extreme temperature ( esp cold)

• Infectious illness

3. Symptoms of Fibromyalgia

l  Generalized pain — 100% of people with fibromyalgia

l  Stiffness, worse in morning and evening

l  Moderate to severe fatigue, weakness

l  Poor sleep

l  Intolerance of cold, swollen feeling in tissue, anxiety, dry eyes and mouth, problems with memory and concentration

l  Other conditions associated with fibromyalgia:

l  Depression, chronic Headache, migraine, insomnia, TMJ Disorder, myfascial pain syndrome, irritable bowel or bladder, chronic fatigue syndrome

4. Fibromyalgia Massage Therapy

4.1 CONTRAINDICATIONS

• Avoid deep work, overstretching muscle especially during the initial treatment. This might result in pain post treatment

• Do not fatigue the patient with long treatment

• NOTE: Some patients with fibromyalgia who come for massages regularly prefer deep tissue work and/or long treatment, which is why consent and communication (before, during, after) and feedback is important

• Modify massage techniques with patient taking muscle relaxants, analgesics

4.2 TREATMENT

• Massage goals: (full body) Wellness and Relaxation context massage

• Diaphragmatic Breathing

• Level of pressure may vary from area to area and treatment to treatment — (patient feedback)

• Intersperse Swedish massage techniques with stretching, passive movement, joint play

• Key relaxation areas — head, neck , shoulders, abdomen, hands, feet

• The therapist may go over the tender points but don’t treat them like trigger points

 4.3 SELF CARE

• Warm / hot hydrotherapy

• Self massage

• Diaphragmatic breating, meditation, yoga

• Perform exercise at time of day that they feel most energetic — stretch, strengthen, moderate aerobic activity