March is Autoimmune Awareness Month, a time when massage therapists can learn more about autoimmune disorders and how massage might benefit the clients who present with them.
People living with autoimmune disorders is a rapidly growing client population. By current statistics, over one in five, or 50 million, Americans have an autoimmune disorder. Roughly 75% of that cohort is female. There are over 100 known disorders, with new disorders seemingly identified on a regular basis.
Common autoimmune disorders include multiple sclerosis, psoriatic arthritis, Ehlers-Danlos syndrome, lupus, fibromyalgia, Hashimoto’s disorder, rheumatoid arthritis, Crohn’s disease, ankylosing spondylitis, Lyme disease, sarcoidosis and Brown-Sequard syndrome.
Many clients presenting with these disorders can benefit from regular massage therapy, while some such disorders do not generally mix well with massage at all.
Possessing basic knowledge about the most common disorders for which massage is not contraindicated and how you can help these clients can contribute to filling your practice, and make a great difference in the lives of those who live with an autoimmune disorder.
What is an Autoimmune Disorder?
Autoimmune disorders are usually genetic and are then triggered by an overresponse to such external stimuli as bacteria, viruses, stress, hormones and others. Autoimmune disorders are not infectious or contagious.
Such disorders can cause a wide range of symptoms. Severity can range from mildly disruptive to life-threatening. In many cases, these disorders will cause permanent tissue damage over time if left untreated.
A few years ago I was diagnosed with one of the less-common disorders, psoriatic arthritis. Often, getting a diagnosis helps clients explain many of their prior symptoms. I can now look back with much better understanding at aches and pains from years before that seemed weird and hard to explain. Of the hundreds of clients I have worked with, with various disorders, this is a very common story.
While the more common disorders are starting to have a growing body of research on how massage affects them, in general, the research is still scant. You’ll often need to make treatment decisions based on both anecdotal data on client results and feedback from your actual clients to help decide whether massage itself is a good treatment or not in general, and what specific techniques to use.
Keep in mind that none of these disorders have a cure and that all treatment, including medication, massage and others, is about managing symptoms and preventing long-term tissue damage. Some of these disorders, such as my psoriatic arthritis, directly cause symptoms that massage therapists are known for dealing with, such as neck pain, back pain and shoulder pain.
Others, such as Crohn’s disease, attack more internal systems—but the long-term stress of such disorders can pile up and can cause the general musculoskeletal pains massage is known for helping.
How Massage Helps
You will often get clients coming in to you for more general pains and simply need to determine whether massage is contraindicated for any reason due to their autoimmune disorder. A general rule of thumb is that a client who is engaging in normal levels of exercise and activity should be able to receive massage regardless of having an autoimmune disorder.
Whether getting a massage actually helps them feel better, though, can vary from client to client.
For instance, I will often tell my rheumatoid arthritis clients that a majority of the clients I have worked with find more relief of symptoms with acupuncture than deep tissue massage.
Many autoimmune disorders have such large Latin medical words for names that they become easier to talk and write about using acronyms. I’ve personally worked with clients with dozens of different disorders, and I seem to be gaining a reputation for helping them as I’m finding more new clients with rare disorders I’ve never heard of before coming in for massage treatments.
In general, these clients are already well-versed on the impact their disorder has on their bodies and come in reasonably sure about whether massage can help them. Other such clients have tried many different treatment modalities and are willing to experiment to see if massage helps them.
Intake Recommendations
If a client arrives and tells you about a disorder you have never heard of before, it’s worth taking a moment to do some on-the-spot online research to gain a basic understanding of the disorder and to look for any known contraindications that would rule out massage in general or specific techniques.
Stick to such well-known and respected sources as the National Institutes of Health or a renowned nonprofit organization, such as the Arthritis Foundation, that is focused on the specific disorder.
You certainly don’t need to find out every known detail about the autoimmune disorder, but it helps a lot to understand the main symptoms and the types of body tissue/s the disorder attacks during flare-ups. It is also worth noting any secondary symptoms that go along with the disorder, such as headaches, fatigue or anxiety.
You don’t need to try to pretend you know everything about all disorders. The rarer the disorder, the more likely the client themselves has done their own reading and discussed massage with their medical care team.
However, it is still worth familiarizing yourself with the disorder to potentially rule out specific techniques. For instance, you would want to avoid deep stretching and range-of-motion work with someone with the type of Ehlers-Danlos syndrome that causes easily torn ligaments, but you can still do light-to-medium work directly on their muscles.
Ask clients if they have previous experience getting massage and what sorts of techniques they know will bring them relief, and if there are any techniques that have aggravated their symptoms. Knowing their prior experience will help you craft a treatment that is most likely to help them and least likely to harm them.
If the client presents with a disorder you are already familiar with, be transparent about whether massage—and your specific style—has helped your other clients and what sort of approaches you have developed based on your experience.
For instance, for some chronic inflammatory disorders such as rheumatoid arthritis or fibromyalgia, deep tissue techniques have a tendency to flare up symptoms and make them worse for several days with no seeming benefits afterward for a majority of the clients I have worked with.
Every so often, a client with those disorders does like the results of deep tissue work, but I warn these clients that my style of massage, which is mostly myofascial release, isn’t usually suited to most people with their disorder.
Often, acupuncture, cranial sacral or another lighter modality works better for these clients and I will let them know this. Ask the client to be honest with themselves and me about the results of a first session with me. They may still choose to try out a deeper-tissue session to find out for themselves if they are in the minority of clients who do get good results from it.
On the other hand, they may choose to opt to start with lighter work with me. I let them make the choice. Most of these clients are in the middle of the process of learning about their disorder and are willing to experiment with different treatments to see what works best for them.
Constant vs. Episodic Symptoms
One intake question that can help you determine whether massage work will be likely to help the autoimmune disorder sclient is to ask if their symptoms are constant, meaning daily, or episodic, meaning generally not too bad but with sudden onsets of more intense symptoms.
Clients with constant symptoms may find that massage, especially deeper work, overtaxes their already constantly burdened systems. Instead of relieving their symptoms, massage can actually make them feel worse for several days without a payoff afterward.
On the other hand, clients with episodic symptoms are very likely to find relief from massage, and regular sessions can be a helpful prevention for future attacks. Advise these clients to try to schedule their massages for when their symptoms are either nonexistent or light.
You may need to think about your protocols and policies for how to handle clients who have a sudden flare-up the day they are scheduled to come in. If this happens only occasionally, you can treat the client like any other client who gets sick occasionally; however, if they regularly cancel on the day of their appointment, you may need to set some boundaries to prevent them from negatively affecting your income.
Clients can swing between these ends of the spectrum as well—constant and episodic—so be willing to alter your approach depending on where they are at in their symptom cycles.
Contraindications for Massage
In general, clients with autoimmune disorders have already discussed getting massage with their medical team and made a determination on whether it is indicated or not. However, some clients do not think to ask their team, or have self-assessed their autoimmune disorder and may not be aware of some reasons massage could be contraindicated.
Luckily, these contraindications tend to be the same as ones you have already been trained on for your licensure, such as any DVT risks, excessive bruising or open sores, or fever.
If a client has an autoimmune disorder that is in an acute flare-up, deep pressure is generally contraindicated, as it will usually make them feel worse with no sense of relief. However, light pressure and modalities such as reflexology, Trager work, cranial sacral therapy, lymphatic drainage and others may provide immediate relief for these clients.
Both symptoms and how clients react range widely from disorder to disorder and client to client, so be willing to assess on a spectrum and modify treatments based on how clients are feeling that day. I have had clients who usually get very deep work with me when they are asymptomatic but occasionally want a session that is almost Reiki-like during a flare-up.
Know When to Refer Out
Autoimmune disorders attack tissues during flare-ups and these attacks can cause permanent and irreversible damage. Most autoimmune medications are intended to prevent flare-up attacks and the damage they can cause. The fact that they can also treat symptoms such as pain is actually secondary.
A client with MS needs to prevent flare-ups because they can cause permanent and irreversible nerve damage. Similarly, disorders like psoriatic arthritis, sarcoidosis, ankylosing spondylitis and others can have very detrimental, long-term effects on clients if not treated with medications.
The medications available now can allow these clients to continue to lead active and full lives and extend their longevity. Trying to influence clients away from these medications is dangerous and beyond our scope of practice.
On the other hand, you will likely run into clients with active flare-ups and symptom profiles who haven’t had their autoimmune disorder formally diagnosed. These symptom profiles can sometimes look similar to our other clients as they include back pain, neck pain and headaches.
While we are never qualified to diagnose clients under our scope of practice, you will help a lot more people by getting more familiar with assessing possible autoimmune disorders in order to refer clients to a rheumatologist.
Some signs that can indicate a referral is warranted include:
• Symptoms that seem systemic and affect most joints in the body
• Symptoms that don’t seem to respond to massage in the same way as with the majority of your clients or don’t get any better after a few sessions
• Bilateral symptoms that affect the feet and hands such as neuropathy, tingling, itching, pain or swelling.
The Ultimate Goal
Massage and other wellness modalities went through a phase of being called alternative medicine, a phrase that in my opinion continued a non-helpful competition with the medical community.
The newer phrase, integrative medicine, is much better and acknowledges that wellness practices such as massage, acupuncture, yoga, Pilates and others are a valuable addition to the medical community.
Helping your autoimmune disorder clients build and maintain a comprehensive care team that includes you as well as a physician and specialists such as a rheumatologist will serve them toward their ultimate goal: feeling better.
About the Author
David Weintraub, LMT, owns Bodyworks DW Advanced Massage Therapy, a pair of medical massage studios in New York, New York. Bodyworks DW is a National Certification Board for Therapeutic Massage & Bodywork-Approved CE Provider in New York and nationally. His small-group live, webinar and on-demand CE courses offer training on advanced techniques, with a focus on improving assessment and treatment design to get better results with a wide range of clients.