Because massage therapy is classically presented as a healing means that increases blood circulation, considerations need to be thought through when interacting with clients with cardiovascular conditions such as strokes.
Stroke Pathology
Strokes, also referred to as cerebrovascular accidents (CVA), occur when blood flow within the brain is reduced or completely blocked. This prevents brain tissue from receiving blood that conveys oxygen and nutrients to tissues. Urgent medical care is needed when strokes occur as someone can die within hours to minutes upon onset of the stroke incident.
The term Transient Ischemic Attack (TIA) describes a โmini stroke.โ These seem less impactful with less damage occurring with the brain. However, the likelihood of a second stroke, most likely more severe, is highly probable. A TIA survivor needs to evaluate lifestyle factors (including daily diet and exercise) to minimize the chances of another stroke incident.
There are numerous causes associated with stroke incidents. Obstructions caused by thrombi developing within brain vessels or emboli that travel from a distant site to lodge into brain vessels are referred to as ischemic strokes. Strokes resulting from bleeding within the brain are referred to as Hemorrhagic strokes. If the stroke cause is unknown, it may be termed Cryptogenic.
Major risk factors for stroke onset include: sedentary lifestyle, family history of stroke, present cardiovascular disease, clinical hypertension, smoking, Diabetes Mellitus (any type), obesity / overweight and binge drinking of alcoholic beverages.
Incident of Stroke
According to the American Heart Association (AHA) โ2021 Heart Disease and Stroke Statistics Update Fact Sheet,โ strokes accounted for 1 of every 19 deaths in the United States in 2018. This resulted in over 147,000 deaths, ranking strokes 5th in death causality.
Strokes and hemorrhagic incidents fall under the broader category of Cardiovascular Disease (CVD), which is the leading cause of death in the U.S. CVD incidents, as a whole, accounted for over 868,000 deaths in 2017, which surpasses cancer and respiratory deaths.
Stroke incident seems to be declining this century. Age-adjusted death rate by strokes decreased 11.9% over a 10-year span from 2008 to 2018. This followed a 10.2% increase from 1998 to 2008. As more Americans become health conscious and hospital treatments improve, deaths seem to be on a steady decline.
On a worldwide scale, over 6.6 million deaths were recorded in 2019 due to strokes and intracranial hemorrhage incidents. Eastern Europe, Central Asia, Southeast Asia and Oceania were the regions witnessing highest mortality rates.
The 2021 AHA Fact Sheet did not mention COVID-19 at all. There were no comparisons of deaths and incidents comparing cardiovascular disease figures to COVID-19 figures.
Stroke-Related Complications
Common complications associated with strokes include many debilitating effects upon the body. Aphasia, or difficulty speaking, and dysphagia, or difficulty swallowing, can occur as the throat region becomes adversely affected. Alexia, an acquired deficit in the ability to comprehend written language, and agnosia, loss of the ability to identify objects, may result due to damage within the brain itself. Vision may be distorted if the optic nerve is damaged. Confusion and headaches coupled with vomiting may also occur.
Paralysis may result on one side of the body, affecting the face unilaterally or a loss of function within limbs on one side. Dystonia, unintentional sustained muscle contractions, may be witnessed within affected limbs. Impaired coordination and proprioception may result in affected limbs as muscles lose proper communication with the brain. Paresthesia, numbness and tingling may also arise within affected limbs.
Stroke Assessment
A common quick assessment to determine if someone is experiencing a stroke is the mnemonic FAST. This stands for:
F: Face Drooping. Does one side of the face droop or exhibit paralysis, weakness or other abnormalities? If yes, a stroke is likely to have occurred.
A: Arm Weakness. Ask the person to lift both arms in front of their body. Is it difficult to raise one arm? If yes, a stroke is likely to have occurred.
S: Speech. Ask the person to repeat a short sentence such as โMy name is _________.โ If their speech is slurred or difficult to understand, a stroke is likely to have occurred.
T: Time to call 911. Because strokes involving internal brain bleeding, it is essential to call 911 quickly. The person can potentially bleed to death internally, it will be imperative to get the victim to a hospital as soon as possible.
Massage Considerations for Stroke Patients
Massage considerations for stroke patients have been suggested by authors of textbooks often used in entry level massage programs. Following these suggestions will make a massage therapistsโ efforts with stroke patients easier when attempting to achieve client rehabilitation goals.
Kalyani Premkumar MD, in her book, โPathology A to Z โ A Handbook for Massage Therapists,โ recommends that important goals for stroke patients is to address joint stiffness, decrease muscle spasticity, reduce skin changes, address postural changes, and re-educate client movement pattern via improving sensory stimulation. Incorporating light touch techniques can help with improving sensory neurons regain stimulation capabilities. Adding stretching to sessions can aid the joint stiffness. Using static compression upon a muscle region may help with decreasing spasticity.
Premkumar mentions two more important ideas in her textbook. First, be sure to communicate and work in conjunction with a patientsโ other allopathic therapists such as an Occupational Therapist. Second, clonus (abnormal involuntary muscle contractions) of the ankle of region is common for stroke patients. Do not forget about the feet and ankle regions. Reflexology and other foot massage techniques will be helpful in this case.
Ruth Werner, in her textbook, โA Massage Therapistโs Guide to Pathology,โ discusses the risks and benefits of massage to stroke patients. Ms. Werner states the major risk of a massage to a stroke patient is the possibility of another cerebrovascular accident and threat of another stroke incident occurring. Since massage therapy increases blood circulation, slowing down our massage and focusing on one body region rather than full body massage are two good suggestions how to alleviate these risks.
Werner informs that massage and other therapeutic means that include gentle stretching, exercises and building awareness will be effective additions to a stroke patientโs treatment plan. Gentle range of motion, light myofascial release techniques including skin traction and gentle tapotement can help sensory neurons improve proprioceptive messages to enhance awareness within the nervous system.
Susan Salvo, in her textbook โMassage Therapy Principles and Practice,โ includes many massage considerations for patients with cardiovascular conditions. If strokes are in connection with hypertension, check in about any sensations of dizziness in correlation with massage. Have client sit up in dizziness experienced. Ms. Salvo adds studies in her textbook how massage upon the back can reduce blood pressure, decrease heart rate and improve parasympathetic activity.
Salvo also describes massage modifications for Peripheral Arterial Disease (PAD), which may contribute to stroke incident. Avoid deep, vigorous massage for these patients. Rather, remain light with pressure application to avoid further stressing arteries potentially possessing a clot. Signs of blood clot include unilateral swelling, discoloration of local skin, changes in local skin temperature and puffy appearance of local vessels.
When working with stroke patients in my private practice, I also consider these ideas:
For patients with history of stroke, I ensure during intake to assess general cognition in terms of how well they are communicating with me and moving. I have them walk my long hallway a couple of times so I can assess gait noting any changes or disruptions.
I also inquire about medications taken and side effects they are currently experiencing. Common medications taken by stroke patients include thrombolytics (Eminase, Retavase, Streptase) to dissolve blood clots, anticoagulants (Warfarin, Heparin) and antiplatelets (Plavix, Effient, Aspirin, Novasen) to limit formation of new clots and antihypertensive (ACE inhibitors, Calcium channel blockers) medications to manage blood pressure. Common side effects of these drugs include gastrointestinal challenges, blurry vision, headaches and fatigue.
During a massage session, I will check in to ensure the client can still communicate verbally throughout the session. When working the neck region, I keep the work less intense to reduce blood flow expedition into the cranium. I include cranial sacral therapy to induce relaxation on central nervous system tissues.
An important reminder here is that cranial sacral therapy or massage of any kind is contraindicated within six weeks of a recent stroke incident.
During a session, I include stretching and lighter myofascial release techniques when I feel adhesions in muscle and fascial tissues. More of my focus is upon the hips and legs to promote more blood flow circulation to the lower limbs.
Research on Massage for Stroke Patients
There is research confirming the effects of massage therapy upon stroke patients in alleviating their symptoms. In โEvaluating the Efficacy of Massage Intervention for the Treatment of Poststroke Constipation: A Meta-Analysis,โ researchers suggest that massage can be an effective means to reduce the effects of constipation in stroke patients in meta-analysis conducted.
Ayurvedic-based massage can promote healing in patients with flaccidity of muscles and lead to less need for antispastic drugs, according to a 2019 study in the Journal of Ayurvedic Integrative Medicine. This was observed in study with people who has experienced both simple and complex strokes.
Adding aromatherapy and foot baths into treatments with stroke patients showed such benefits as reduced stress, improved mood and increased sleep satisfaction (even greater than those receiving only massage) of stroke patients in a study published August 2017 in the Journal of Physical Therapy Science.
In a 2020 study on the effects of tactile massage with stroke patients Nursing Open Journal showed how physical touch eased worries and anxiety sensations felt by patients. Also, physical touch generated feelings of closeness and improved sleep satisfaction.
With the information gathered from research articles and trusted textbooks, a treatment plan for stroke patients is possible. It is my experience that stroke patients benefit greatly from massage and cranial sacral therapy. Awareness of medications taken, the functional impact of the stroke and how the body is responding to massage will help guide a therapist on necessary modifications.
For More Information:
National Stroke Foundation
American Stroke Foundation
American Heart Association
About the Author
Jimmy Gialelis, LMT, BCTMB, is owner of Advanced Massage Arts & Education in Tempe, Arizona. He is a National Certification Board for Therapeutic Massage & Bodywork-approved provider of continuing education, and teaches โProfessional Ethics for LMTsโ and many other CE classes. He is a regular contributor to MASSAGE Magazine, and his articles include โMassage for Trauma: 3 Ways of Responding to an Emotional Releaseโ and โTMJD: How to Assess for Dysfunction.โ
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Stroke Pathology
Strokes, also referred to as cerebrovascular accidents (CVA), occur when blood flow within the brain is reduced or completely blocked. This prevents brain tissue from receiving blood that conveys oxygen and nutrients to tissues. Urgent medical care is needed when strokes occur as someone can die within hours to minutes upon onset of the stroke incident.
The term Transient Ischemic Attack (TIA) describes a โmini stroke.โ These seem less impactful with less damage occurring with the brain. However, the likelihood of a second stroke, most likely more severe, is highly probable. A TIA survivor needs to evaluate lifestyle factors (including daily diet and exercise) to minimize the chances of another stroke incident.
There are numerous causes associated with stroke incidents. Obstructions caused by thrombi developing within brain vessels or emboli that travel from a distant site to lodge into brain vessels are referred to as ischemic strokes. Strokes resulting from bleeding within the brain are referred to as Hemorrhagic strokes. If the stroke cause is unknown, it may be termed Cryptogenic.
Major risk factors for stroke onset include: sedentary lifestyle, family history of stroke, present cardiovascular disease, clinical hypertension, smoking, Diabetes Mellitus (any type), obesity / overweight and binge drinking of alcoholic beverages.
Incident of Stroke
According to the American Heart Association (AHA) โ2021 Heart Disease and Stroke Statistics Update Fact Sheet,โ strokes accounted for 1 of every 19 deaths in the United States in 2018. This resulted in over 147,000 deaths, ranking strokes 5th in death causality.
Strokes and hemorrhagic incidents fall under the broader category of Cardiovascular Disease (CVD), which is the leading cause of death in the U.S. CVD incidents, as a whole, accounted for over 868,000 deaths in 2017, which surpasses cancer and respiratory deaths.
Stroke incident seems to be declining this century. Age-adjusted death rate by strokes decreased 11.9% over a 10-year span from 2008 to 2018. This followed a 10.2% increase from 1998 to 2008. As more Americans become health conscious and hospital treatments improve, deaths seem to be on a steady decline.
On a worldwide scale, over 6.6 million deaths were recorded in 2019 due to strokes and intracranial hemorrhage incidents. Eastern Europe, Central Asia, Southeast Asia and Oceania were the regions witnessing highest mortality rates.
The 2021 AHA Fact Sheet did not mention COVID-19 at all. There were no comparisons of deaths and incidents comparing cardiovascular disease figures to COVID-19 figures.
Stroke-Related Complications
Common complications associated with strokes include many debilitating effects upon the body. Aphasia, or difficulty speaking, and dysphagia, or difficulty swallowing, can occur as the throat region becomes adversely affected. Alexia, an acquired deficit in the ability to comprehend written language, and agnosia, loss of the ability to identify objects, may result due to damage within the brain itself. Vision may be distorted if the optic nerve is damaged. Confusion and headaches coupled with vomiting may also occur.
Paralysis may result on one side of the body, affecting the face unilaterally or a loss of function within limbs on one side. Dystonia, unintentional sustained muscle contractions, may be witnessed within affected limbs. Impaired coordination and proprioception may result in affected limbs as muscles lose proper communication with the brain. Paresthesia, numbness and tingling may also arise within affected limbs.
Stroke Assessment
A common quick assessment to determine if someone is experiencing a stroke is the mnemonic FAST. This stands for:
F: Face Drooping. Does one side of the face droop or exhibit paralysis, weakness or other abnormalities? If yes, a stroke is likely to have occurred.
A: Arm Weakness. Ask the person to lift both arms in front of their body. Is it difficult to raise one arm? If yes, a stroke is likely to have occurred.
S: Speech. Ask the person to repeat a short sentence such as โMy name is _________.โ If their speech is slurred or difficult to understand, a stroke is likely to have occurred.
T: Time to call 911. Because strokes involving internal brain bleeding, it is essential to call 911 quickly. The person can potentially bleed to death internally, it will be imperative to get the victim to a hospital as soon as possible.
Massage Considerations for Stroke Patients
Massage considerations for stroke patients have been suggested by authors of textbooks often used in entry level massage programs. Following these suggestions will make a massage therapistsโ efforts with stroke patients easier when attempting to achieve client rehabilitation goals.
Kalyani Premkumar MD, in her book, โPathology A to Z โ A Handbook for Massage Therapists,โ recommends that important goals for stroke patients is to address joint stiffness, decrease muscle spasticity, reduce skin changes, address postural changes, and re-educate client movement pattern via improving sensory stimulation. Incorporating light touch techniques can help with improving sensory neurons regain stimulation capabilities. Adding stretching to sessions can aid the joint stiffness. Using static compression upon a muscle region may help with decreasing spasticity.
Premkumar mentions two more important ideas in her textbook. First, be sure to communicate and work in conjunction with a patientsโ other allopathic therapists such as an Occupational Therapist. Second, clonus (abnormal involuntary muscle contractions) of the ankle of region is common for stroke patients. Do not forget about the feet and ankle regions. Reflexology and other foot massage techniques will be helpful in this case.
Ruth Werner, in her textbook, โA Massage Therapistโs Guide to Pathology,โ discusses the risks and benefits of massage to stroke patients. Ms. Werner states the major risk of a massage to a stroke patient is the possibility of another cerebrovascular accident and threat of another stroke incident occurring. Since massage therapy increases blood circulation, slowing down our massage and focusing on one body region rather than full body massage are two good suggestions how to alleviate these risks.
Werner informs that massage and other therapeutic means that include gentle stretching, exercises and building awareness will be effective additions to a stroke patientโs treatment plan. Gentle range of motion, light myofascial release techniques including skin traction and gentle tapotement can help sensory neurons improve proprioceptive messages to enhance awareness within the nervous system.
Susan Salvo, in her textbook โMassage Therapy Principles and Practice,โ includes many massage considerations for patients with cardiovascular conditions. If strokes are in connection with hypertension, check in about any sensations of dizziness in correlation with massage. Have client sit up in dizziness experienced. Ms. Salvo adds studies in her textbook how massage upon the back can reduce blood pressure, decrease heart rate and improve parasympathetic activity.
Salvo also describes massage modifications for Peripheral Arterial Disease (PAD), which may contribute to stroke incident. Avoid deep, vigorous massage for these patients. Rather, remain light with pressure application to avoid further stressing arteries potentially possessing a clot. Signs of blood clot include unilateral swelling, discoloration of local skin, changes in local skin temperature and puffy appearance of local vessels.
When working with stroke patients in my private practice, I also consider these ideas:
For patients with history of stroke, I ensure during intake to assess general cognition in terms of how well they are communicating with me and moving. I have them walk my long hallway a couple of times so I can assess gait noting any changes or disruptions.
I also inquire about medications taken and side effects they are currently experiencing. Common medications taken by stroke patients include thrombolytics (Eminase, Retavase, Streptase) to dissolve blood clots, anticoagulants (Warfarin, Heparin) and antiplatelets (Plavix, Effient, Aspirin, Novasen) to limit formation of new clots and antihypertensive (ACE inhibitors, Calcium channel blockers) medications to manage blood pressure. Common side effects of these drugs include gastrointestinal challenges, blurry vision, headaches and fatigue.
During a massage session, I will check in to ensure the client can still communicate verbally throughout the session. When working the neck region, I keep the work less intense to reduce blood flow expedition into the cranium. I include cranial sacral therapy to induce relaxation on central nervous system tissues.
An important reminder here is that cranial sacral therapy or massage of any kind is contraindicated within six weeks of a recent stroke incident.
During a session, I include stretching and lighter myofascial release techniques when I feel adhesions in muscle and fascial tissues. More of my focus is upon the hips and legs to promote more blood flow circulation to the lower limbs.
Research on Massage for Stroke Patients
There is research confirming the effects of massage therapy upon stroke patients in alleviating their symptoms. In โEvaluating the Efficacy of Massage Intervention for the Treatment of Poststroke Constipation: A Meta-Analysis,โ researchers suggest that massage can be an effective means to reduce the effects of constipation in stroke patients in meta-analysis conducted.
Ayurvedic-based massage can promote healing in patients with flaccidity of muscles and lead to less need for antispastic drugs, according to a 2019 study in the Journal of Ayurvedic Integrative Medicine. This was observed in study with people who has experienced both simple and complex strokes.
Adding aromatherapy and foot baths into treatments with stroke patients showed such benefits as reduced stress, improved mood and increased sleep satisfaction (even greater than those receiving only massage) of stroke patients in a study published August 2017 in the Journal of Physical Therapy Science.
In a 2020 study on the effects of tactile massage with stroke patients Nursing Open Journal showed how physical touch eased worries and anxiety sensations felt by patients. Also, physical touch generated feelings of closeness and improved sleep satisfaction.
With the information gathered from research articles and trusted textbooks, a treatment plan for stroke patients is possible. It is my experience that stroke patients benefit greatly from massage and cranial sacral therapy. Awareness of medications taken, the functional impact of the stroke and how the body is responding to massage will help guide a therapist on necessary modifications.
For More Information:
National Stroke Foundation
American Stroke Foundation
American Heart Association
About the Author
Jimmy Gialelis, LMT, BCTMB, is owner of Advanced Massage Arts & Education in Tempe, Arizona. He is a National Certification Board for Therapeutic Massage & Bodywork-approved provider of continuing education, and teaches โProfessional Ethics for LMTsโ and many other CE classes. He is a regular contributor to MASSAGE Magazine, and his articles include โMassage for Trauma: 3 Ways of Responding to an Emotional Releaseโ and โTMJD: How to Assess for Dysfunction.โ
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