Cancer and Massage

Transplant
Bone marrow or stem cell transplant is one of the most taxing treatments used in conventional medicine. Massage therapists planning work with transplant recipients must do so under close supervision by medical staff. The extreme nature of this treatment is described as nothing short of a healing hell.²⁷ Stem cells are precursors to white blood cells, red blood cells and platelets. They are infused in order to counteract effects of radiation and chemotherapy, which then can be administered at much higher doses to destroy the cancer. Side effects prevail from all of the techniques needed to manage bone-marrow transplant for a successful outcome. These side effects can last for many months and even years after the treatment. 
 
Of these side effects, one of the most forbidding is immunosuppression. Medications that suppress the natural immune responses are necessary to prevent both the host and transplant from launching attacks on each other. Immunosuppression is so profound that some period of isolation is often required. Here, standard precautions against infection are inadequate and are replaced by protective isolation precautions. Even after isolation, patients endure fundamental changes in lifestyle required to avoid infection. They must avoid a host of things including housepets, houseplants, many foods and crowds. A massage therapist can learn a great deal from standard patient information materials available at treating hospitals. These booklets help the therapist think about which elements of the massage session put the client at risk of infection. For example, an unwashed bottle of lubricant, a receptionist with a cold, a bolster without a clean surface can all pose dangers to the immunosuppressed.
 
Other treatments cause added side effects that defy the human imagination and require close monitoring. Total body irradiation causes burning and itching on affected areas. High chemotherapy doses intensify the usual chemotherapy side effects. Many aspects of digestion are affected, causing intense mouth sores, changes in salivation, severe constipation, pain, nausea and vomiting. 
 
A few key massage issues are suggested in the sidebar under transplant, but space limits a balanced discussion of the manifold massage adjustments. Massage therapists working with bone marrow patients are strongly advised to do in-depth research to familiarize themselves with these challenges, then work closely with medical staff to keep the client safe. Massage will need to be extremely gentle, limited by overriding medical issues in force.
On the other hand, structured touch can be profoundly helpful to a client in this therapy. Massage can provide a welcome alternative to the familiar pain and discomfort of medical treatment, one of the few forms of contact that is pleasurable and non-invasive, and a relaxation technique that is passive, when more active methods are too challenging.²⁸ Moreover, massage may promote the client's return to exercise, which can improve function.²⁹
 
Other Cancer Treatments
The four common treatments listed above are not a complete list. Other therapies, including biological therapies and hormone treatment, must each be evaluated by the therapist for side effects and other challenges to the client. There are many medications given alongside these treatments, such as steroids, antidepressants, and narcotics, and the massage therapist needs to think clinically about each of these in session design.³⁰ Other considerations for the therapist are posed by the procedures and devices included in those treatments (such as ports, catheters, prosthetics, etc.) and are not mentioned here. Use similar reasoning for any treatment or device. Always gather full information from the literature, the client, and the treating physician about side effects or other issues and assess those in terms of massage therapy. Investigate possible massage adjustments in the available resources,31 and check them with the physician before the session.
 
Step 4-Consider The Client's Stamina, And Adjust 
So far, we have discussed cancer-specific and treatment-specific guidelines. The fourth step is to adjust the massage session to the stamina of the client. This requires good intake questions and close observation. Ask, Are there any medical prohibitions on your level of activity?  or, How have treatments affected your activity level, if at all?  and follow-up with, Does your energy level run through cycles corresponding to your treatment, or the hour of the day, etc.?  Follow-up questions give the massage therapist information needed to tailor the session for a given day and time. Learn more about energy level by observing the client closely. Notice their attention span, whether their breathing is labored or uneven, or punctuated by sighs. During conversation, notice whether their eyes glaze over easily. 
 
If stamina and strength are compromised, the vigor of the massage must be adjusted in kind, primarily in the following three areas: 

• Speed (slow speeds are best);

• Duration (consider shortening the massage by half, or even much more);

• Pressure (in general, gentler pressure is necessary when people are challenged by cancer treatments and who may experience fatigue and pain, etc.). 

For this calibration, the therapist needs to be exquisitely attuned to the situation. Take the force of each of these massage components down several notches, at least. Use observation and a measure of intuition to judge how lightly to work. In general, do not ask the client's body to do any additional work. Do not press so hard that the client needs to resist. Bolster the client's body so that the client needs no effort to hold a position. Do not employ resisted movements, nor even passively move the limbs through wide ranges of space. In short, do not challenge the client's body confine the therapy to techniques that provide comfort and ease. Nothing needs to be altered or fixed, it just needs attention. Pay close attention to the client's responses to touch. Look for changes in breathing, fluttering eyelids, clenched fists or other tightly held muscles for cues about how the massage is being received. 
 
Intuition, as highly-prized as it is in this profession, can be off-kilter, just as information can be inaccurate. Massage therapists with fairly accurate intuitive powers can still have an "off" day. Intuition is a powerful assessment tool, but it is not foolproof and should not be used in isolation. Any challenging scenario may cloud intuition just as easily as it may refine it. The best combination to assess stamina, a dim parameter, is one of intuition, information, and skill. 
 
To accommodate a client's energy level, note that vigorous massage techniques are inadvisable for most clients in cancer treatment, and may be only sparingly applied in the months of recovery from the last treatment. The year (or more, if a bone marrow recipient) following treatment is often a tender one that demands intensive self-care for the body. Healing and rejuvenation can come slowly, and side effects can take months to subside. Respect the process. This is a period of testing stamina, ups and downs in health, and concern about infection. When a client's body is processing medications and battling cancer, honor their course of recovery. Massage is an opportunity to approach the body with care, attention and acceptance. The client still may need all of their resources to convalesce. 

Crafting The Health History 
Additional guidelines for working with people with cancer, presented in the table, are explained in more depth in the literature.³² Readers are referred to those resources, to the client's medical staff and to the available literature on cancer treatment. 
 
One simple way to begin a history form is to take each safe practice suggestion listed in the literature and convert it to a question. Done for each guideline, this generates a list of questions that the therapist needs to ask before proceeding with the session. To practice clinical thinking in this area, massage therapists should start by creating their own forms first, then checking them for completeness against other forms in common use. 
 
Use care and sensitivity in wording the question, especially when interviewing the client. Wording is everything. Instead of asking if there is metastasis, the practitioner might, instead, ask about the type of cancer and where it's located in the client's body. Establish rapport by asking questions sensitively and conversationally.³³
 
With this rapport in mind, it is possible to take each of the principles and assemble a list of questions for the client and the client's treating physicians or nursing staff that will elicit the needed information. In brief, you will need to know the type of cancer, the location, the names of the treating physicians,34 the course of the cancer treatments, any side effects of treatment, and the client's general stamina level. These bits of information will generate another list, of massage restrictions and possible benefits to guide the massage session. It is good practice to write out a complete detailed list, or decision tree, for a sample interview. More streamlined history forms are available, and one may be found in MacDonald's Medicine Hands. There, massage limitations are grouped into site, pressure and positioning restrictions.³⁵ 
 
Answers to the medical history questions give the massage therapist key information for planning the massage, but they also provide some idea of the texture of the client's days. This has practical applications: For example, if radiation treatment is daily at 8:30 a.m., it may be possible to schedule massage sessions one hour after that, since radiation treatments tend to stay close to schedule. But other benefits of a complete health history are as important; with this information, a massage therapist may be able to form a stronger, more compassionate connection with the client. 
 
A complete list of necessary questions would present a client with a long, imposing, potentially intrusive form to fill out, and the art of history-taking is not obvious in any list of prescribed questions. Some finesse is necessary in order to avoid an interrogation. A good intake interview is warm, conversational and yields complete information. In the wash of treatments, clients may forget key details or treatments that are important to the therapist. The practitioner should repeat important questions in different styles to be sure to obtain the needed information. Listen reflectively, and use the chance to cultivate that connection.