Friday, 24 June 2016

Is Massage Really Wise For Neuropathy?

Today's post from (see link below) warns about the possible disadvantages of massage therapy. Many people with neuropathy symptoms somehow assume that massage will help them feel better and in many cases they do but you need to go to a massage therapist who knows what he or she is doing. The idea that you may come away with symptoms that are worse than before should be enough to make you think about whether a good pummelling is really good for your nerves or not. Gentle massage may well be very effective in calming down painful nerve areas, or generally making you relax but the minute the masseur goes for deep tissue and joint massage may be the moment you ask how much experience he or she has with neuropathy. You probably know yourself, if you've tried massaging your neuropathic feet. Half the time you can't feel anything due to the numbness but the moment you push just that little bit too hard to relieve the burning or tingling, you can be suffering for days. Always best to go to a qualified masseur with relevant experience, or else the happy ending may not be as happy as you thought (goes for all kinds of massage!!)

What Could Possibly Go Wrong With Massage?
Rare but real adverse effects of massage therapy, especially “deep tissue” massage
updated July 16 2014 by Paul Ingraham, Vancouver, Canada bio

People think of massage therapy as a “safe” therapy, and of course it mostly is. But things can go wrong, or at least a bit sour. While serious side effects in massage therapy are extremely rare, minor side effects are downright common. A 2007 survey of 100 massage patients1 found that 10% of 100 patients receiving massage therapy reported “some minor discomfort” in the day following treatment. This would mainly be a familiar slight soreness that is common after a massage, known as “post-massage soreness and malaise” (PMSM) — and I’m surprised only 10% reported it. The massages they were getting must have been quite gentle.2

Interestingly, 23% reported unexpected benefits that had nothing to do with aches or pains. (Benefits for musculoskeletal problems were not documented.)

This study is underpowered. It cannot and does not rule out rare and/or serious side effects of massage therapy, which do exist. You could probably do several studies of 100 patients without encountering a single nasty situation. But what if you surveyed 1,000 patients? Or 10,0000? Massage is not completely safe — what is? — and other adverse effects would almost certainly turn up in a big enough survey. Nevertheless, according to one of alternative medicine’s most vigorous critics, Dr. Edzard Ernst, “Serious adverse events are probably true rarities.”3 And yet, reviewing the literature again in 2013, Ernst and Posadzki found at least 18 reported examples of “moderately severe” reactions to normal massage, especially of the neck.4
When massage goes bad

So what could possibly go wrong? Massage can…
directly cause new injuries (mostly quite minor, but not all)
aggravate existing injuries and chronic pain problems
distract patients from more appropriate care
mildly stress the body And don’t forget, of course, that that pointlessly draining your wallet is another kind of pain. If someone spends $5,000 on massage therapy that has only a minor therapeutic effect, or none at all, is that an “injury”? It’s an insult, at the least!

In my decade (2000–2010) as a massage therapist, I met many patients who had been harmed by massage therapy to some degree — fortunately, mostly just expensive disappointments and minor backfires, but quite a few more serious cases too.5 

Sensory injury

A painful, alarming sensory experience can actually dial up pain sensitivity — even long term.6 Furthermore, vulnerability to this awful phenomenon is much more common and significant in desperate patients who already have chronic pain — so they seek and tolerate intense therapy. People experiencing pain system dysfunction can have minor & major setbacks in response to excessively painful massage.

The experience of pain is affected by many factors, including emotional and psychological ones. People in chronic pain usually experience some degree of pain neurology dysfunction, and a breakdown of the relationship between how bad things feel and how much is really wrong. That breakdown can be seriously worsened by threatening sensations. Thus, people experiencing pain system dysfunction can have minor and major setbacks in response to excessively painful massage.

One of my readers suffered this kind of disaster. She was injured by “fascial release” therapy, a style which is often too intense and may focus on treating connective tissues to the exclusion of considering the patient’s comfort and nervous system.

I may have been too aggressive with a few patients over the years. I never did serious harm this way as far as I know, but I’m sure that I occasionally did more harm than good. This failure was due entirely to my ignorance of pain science: despite being an unusually well educated massage therapist, I simply did not know that an intense massage could change pain sensitivity itself. Does your therapist?
Pain is Weird Pain science reveals a volatile, misleading sensation that is often more than just a symptom, and sometimes worse than whatever started it ~ 9,000 words
The Pressure Question in Massage Therapy What’s the right amount of pressure to apply to muscles in massage therapy and self-massage? ~ 4,500 words
Poisoned by massage

Excessive pressure probably has another predictable outcome: a light poisoning. Seriously.

For example: an 88-year old man collapsed the day after an unusually strong 2-hour session of massage therapy.7 He had too much myoglobin in his blood, and it was poisoning his kidneys and generally making him feel rotten. It’s not a sure thing that his condition was cause by the massage — but it is quite likely. It is almost certainly a perfect example of one of those rare but serious complications of massage. Another case study comes up below.

Ironically, many people believe that massage is a detoxification treatment, but in fact it’s probably the opposite. Ironically, many people believe that massage is a detoxification treatment, but in fact it’s probably the opposite. Post-massage soreness and malaise is probably caused by mild rhabdomyolysis (“rhabdo”): poisoning by the waste products of injured muscle.

True rhabdo is a medical emergency in which the kidneys are poisoned by myoglobin from muscle crush injuries. But many physical and metabolic stresses cause milder rhabdo-like states — even just intense exercise, and probably massage as well. There are many well-documented cases of exertional or “white collar” rhabdo, and there is a strong similarity between PMSM and ordinary exercise soreness. A rhabdo cocktail of waste metabolites and by-products of tissue damage is probably why we feel a bit cruddy after all biological stresses and traumas — including massage, sometimes.

PMSM is just an unavoidable mild side effect of strong massage. And for a few more vulnerable patients, it could actually be a little dangerous.
Poisoned by Massage Rather than being “detoxifying,” massage may cause a modestly toxic situation in the body ~ 4,500 words 

Other examples of massage wounds

The neck is not generally a fragile structure, but it is in some people. Another serious example of an adverse effect of massage is what happened to my barber — either a brain stem injury or mini-stroke caused by careless massage of a vulnerable neck. One of my own patients was injured the same way by another therapist, vomiting and retching for hours afterwards (a nasty symptom of brain stem impingement, or ripping of an artery going to the brain). I came close to doing this to another patient — that’s three examples of such patients in my career — but I’m proud to say that I spotted the warning signs and avoided disaster.

A weird case of brain artery damage (extracranial internal cartoid artery dissection, specifically) was reported in 2004 by the Southern Medical Journal: a 38-year-old woman gave herself a stroke by using a vibrating massage tool for long and too hard on her neck.8 Obviously such an incident has little to do with professional massage. Nevertheless, it demonstrates that the arteries of the neck are a little bit fragile — and I have no doubt that there are poorly trained or incompetent therapists out there would might get carelessly exuberant in this region, while trying to treat the scalenes: see Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain.

Another weird, extreme case study paper tells the horror story of one person’s awful experience with a severe reaction to (apparently) infrared heat and massage therapy.9 The trouble started after several treatments. His neck and arms were swollen, the pain became “unbearable,” and his “serum muscle enzymes were increased” — which means some degree of rhabdo, which implicates the massage itself as a significant mechanism of injury. Massage is not likely to “blame” for the incident, though — it was probably interacting with some unidentified vulnerability in the patient, such a muscle disease or a complication caused by a medication. Clearly massage and heat alone do not normally cause such severe side effects! Nevertheless, the potential for very unpleasant interactions exists.

“Alternative therapies may have serious complications, and patients usually do not report them unless asked specifically,” the authors point out.

I am one-degree of separation from a patient whose femur (the big leg bone!) was fractured by a massage — it was a weak and injured femur already … but wow!

Nerves aren’t nearly as vulnerable to pressure as people generally think — most of them can actually take quite a licking and keep on ticking without a single symptom — but they aren’t invulnerable. And I once caused a nerve injury myself: it was a minor injury, but it did — augh — result in weeks of aggravating discomfort for my client. The Archives of Physical Medicine & Rehabilitation reported a similar spinal accesory nerve injury: “a rare and illustrative case of spinal accesory neuropathy associated with deep tissue massage leading to scapular winging [the shoulder blade sticking out] and droopy shoulder as a result of weakness of the trapezius muscle.”10
What Happened To My Barber? Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers ~ 2,750 words 

Lessons for professionals and patients

These are rare but real incidents. Healthy people are unlikely to be injured by massage. Most of dangers are related to undetected vulnerabilities, and they emphasize the importance of alternative health professionals being trained to spot the scary stuff. The measure of a health professional’s competence is not what they do with relatively healthy patients, but whether they have the training and humility to realize when they are on thin ice.

Manual therapists need to know that the most important part of their job is the smart management high-risk situations that they may see only a handful of times in their entire career. It’s like being on guard duty: 99.9% of the time, nothing bad happens. But how do you handle a curve ball when it finally comes?

Consumers need to know that cocky, overconfident therapists who trash-talk “mainstream” health care are all-too-likely to be ignorant of critical warning signs, or dismissive of them. The skeptical salamander thinks these therapists shouldn’t be allowed to touch anyone. See Missing Serious Symptoms.

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Cambron JA, Dexheimer J, Coe P, Swenson R. Side-effects of massage therapy: a cross-sectional study of 100 clients. J Altern Complement Med. 2007 Oct;13(8):793–6. PubMed #17983334. BACK TO TEXT

Indeed, that seems very likely given the context. I doubt they would test painfully strong massage on 100 people without mentioning the intensity. However, painfully strong massage is quite common “in the wild.” Certainly intense massage is unusually common here in Vancouver, where there’s a regrettable professional predeliction for it. BACK TO TEXT
Ernst E. The Safety of Massage Therapy. Rheumatology. 2003;42 (9):1101–1106. PubMed #12777645. PainSci #54834.

Is massage safe? Researchers attempted to answer that question. Four databases were reviewed; all articles which reported adverse effects of any type of massage therapy were looked at. In the end, 20 reports were looked at. “The majority of adverse effects were associated with exotic types of manual massage or massage delivered by laymen, while massage therapists were rarely implicated.”

The conclusion was that, while not entirely risk free, “serious adverse events are probably true rarities.” BACK TO TEXT
Posadzki P, Ernst E. The safety of massage therapy: an update of a systematic review. Focus on Alternative and Complementary Therapies. 2013;18(1):27–32. PainSci #53974.

OBJECTIVE: To update a systematic review evaluating the safety of massage therapy.

METHODS: A literature search was carried out using four electronic databases for the period December 2001 to May 2012. All articles reporting adverse effects of massage therapy were retrieved. Adverse effects relating to atypical massage, aromatherapeutic massage oil or ice were excluded. No language restrictions were applied. Data were extracted and evaluated according to predefined criteria.

Seventeen case reports and one case series were published since our previous review. The reported adverse effects comprised acute paraplegia and abdominal distension, bladder rupture, bilateral cerebellar infarction, cervical lymphocele, cervical cord injury, cervical internal carotid and vertebral dissection, chylothorax, haematuria, interosseous nerve palsy, myopathy, perinephric haemorrhage, rhabdomyolysis, severe headache, blurred vision, paraesthesia and focal motor seizures. In the majority of the reports, a cause–effect relationship was certain or almost certain. Serious adverse effects were most commonly associated with massage techniques applied to the neck area.

Evidence suggests that massage may occasionally lead to moderately severe adverse effects. BACK TO TEXT

Several dozen at least who experienced minor negative effects and a lighter wallet. I recall only about dozen or so having really poor experiences, mostly aggravated chronic pain. Only a handful of those were obviously significantly injured by massage. But those were sad cases. BACK TO TEXT

Woolf CJ. Central sensitization: Implications for the diagnosis and treatment of pain. Pain. 2010 Oct;152(2 Suppl):S2–15. PubMed #20961685. PainSci #54851.

Pain itself often modifies the way the central nervous system works, so that a patient actually becomes more sensitive and gets more pain with less provocation. That sensitization is called “central sensitization” because it involves changes in the central nervous system (CNS) in particular — the brain and the spinal cord. Victims are not only more sensitive to things that should hurt, but also to ordinary touch and pressure as well. Their pain also “echoes,” fading more slowly than in other people.

For a much more detailed summary of this paper, see Central Sensitization in Chronic Pain. BACK TO TEXT

Lai MY, Yang SP, Chao Y, Lee PC, Lee SD. Fever with acute renal failure due to body massage-induced rhabdomyolysis. Journal of Nephrology, Dialysis and Transplantation. 2006 Jan;21(1):233–4. PubMed #16204282. PainSci #54301. BACK TO TEXT

Grant AC, Wang N. Carotid dissection associated with a handheld electric massager. South Med J. 2004 Dec;97(12):1262–3. PubMed #15646768. BACK TO TEXT

Tanriover MD, Guven GS, Topeli A. An unusual complication: prolonged myopathy due to an alternative medical therapy with heat and massage. South Med J. 2009 Sep;102(9):966–8. PubMed #19668045. BACK TO TEXT

Aksoy IA, Schrader SL, Ali MS, Borovansky JA, Ross MA. Spinal accessory neuropathy associated with deep tissue massage: a case report. Arch Phys Med Rehabil. 2009 Nov;90(11):1969–72. PubMed #19887226. BACK TO TEXT

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