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Chemotherapy and Massage
11 Questions to Ask Your Clients

By Tracy Walton

Originally published in Massage Bodywork magazine, May/June 2011. Copyright 2011. Associated Bodywork and Massage Professionals. All rights reserved.

My work with people with cancer engages my hands and my whole heart. As my hands travel across the body, each client's story expands my heart and skills a bit. Also, because of this work, both sides of my brain get exercise. The right side is making intuitive decisions, and the left side is processing the multiple side effects and massage adjustments that come with chemotherapy.

In this article I highlight some of the interviewing and decision-making processes I use when working with people in chemotherapy. I emphasize the effects of chemotherapy, the interview questions we use to target those effects, and concrete massage adjustments for some key side effects. When I work with medically complex clients, I need specific, concrete guidelines, so I've worked to provide them for other therapists as well. I hope the following information can make massage better, more tolerable, and potentially more helpful to people in chemotherapy.

What Is Chemotherapy?
Chemotherapy is the systemic use of drugs to treat cancer by interfering with the growth of cancer cells. Many types of chemotherapy have been developed to shrink tumors or eliminate them entirely, hold off the spread, defeat cells that have already spread to secondary sites, and relieve cancer symptoms.

Chemotherapy is administered on an outpatient or inpatient basis. Because it is such strong medicine, it is generally delivered in cycles of doses alternating with rest periods. Medication can be taken orally or administered intravenously by infusion. A device called an implantable access port (IAP or simply "port") can be surgically implanted under the skin, serving as a reservoir to distribute drugs into the bloodstream. The reservoir can be accessed by a needle for intravenous (IV) infusion, eliminating the need for repeated needle sticks or IVs. A common port site is the chest, as shown in Image 1. A port may also be implanted in the abdominal cavity for intraperitoneal infusion. In some cases a chemotherapy drug is introduced directly into an area of cancer in the body so that it contacts the tumor at full strength, before it is diluted in the bloodstream.

A medical oncologist determines the kind of chemotherapy and the dose. Medications might be administered once every 2-4 weeks, weekly, or several times a week. Some are infused continuously over a few days. Oral pills might be taken daily, or less often.

Chemotherapy Side Effects
The side effects of chemotherapy are legendary. Because chemotherapy is delivered systemically, and because the drugs are in the bloodstream, they can have strong effects on normal cells in the body and on the body's systems.

General Effects.
Fatigue can range from slight tiredness to profound, chronic exhaustion. Chemotherapy diminishes blood cell production by the bone marrow, an effect called myelosuppression. As a result, cytopenias occur: blood levels of one or more blood cell types (red blood cells, white blood cells, or platelets) drop. Blood cell counts are monitored closely before each chemotherapy infusion to determine whether the treatment can proceed or a rest is needed for the numbers to come back up.

Bone marrow suppression produces thrombocytopenia (low platelets), which causes easy bruising or bleeding; anemia (low red blood cell counts), which causes fatigue, light-headedness, and cold intolerance; and neutropenia (low neutrophils--the white blood cells that fight bacteria), which causes a heightened vulnerability to infection.

When chemotherapy affects blood cell counts, the effects can range from mild to severe, depending on how low the counts drop. Platelets can be slightly low, with no detectable effect on bruising, or they can be profoundly low, with easily bleeding gums, or even the life-threatening danger of bleeding out of major organs (hemorrhage). Neutropenia can be mild, with a slight susceptibility to infection, or severe, requiring the use of masks and gloves to avoid infecting the person. Anemia can be mild, or severe enough to strain the heart as it compensates by working harder to pump the oxygen-poor blood to the tissues.

Gastrointestinal effects (GI).
Side effects of chemotherapy that affect the GI tract include constipation, diarrhea, nausea, and vomiting. Mouth sores, known as stomatitis or mucositis, make chewing food difficult. Loss of appetite is common with chemotherapy and can be due to changes in taste and smell, nausea, and mouth sores.

Effects on the skin and hair.
Hair loss is probably one of the most devastating side effects of chemotherapy, because it affects body image, and because it is the most outward sign of cancer treatment. In addition, skin changes are common, and this includes inflammation, rash, and chapping of the skin. In hand-foot syndrome, a response to some chemotherapy treatments, the feet and hands become chapped, irritated, and swollen. Toenails or fingernails may become discolored or fall off. This condition can make walking very painful, and make it difficult to use the hands.

Neurological effects.
Peripheral neuropathy is common in the hands and feet, and may even extend further up the extremities. It causes pain, burning, tingling, or numbness in those areas. Chemobrain (also called brain fog) is a chronic loss of memory, attention, and focus specifically attributed to chemotherapy. Both neuropathy and chemobrain typically fade in the weeks and months after chemotherapy is completed, but in some people they persist long-term.

These are just some of the key effects of chemotherapy. Others are addressed in the oncology massage literature, notably in references provided at the end of this article.

The Massage Approach To Chemotherapy
Chemotherapy places heavy demands on the body, and the massage should be low-impact. Massage should not ask anything more of the body. This cannot be emphasized enough. The intent of massage should be to support the body and its efforts to integrate strong medical treatment. For this reason, gentle pressure, in the range of "light and heavy lotioning," (Images 2A and 2B) is the best pressure for most people. Moderate pressure may be possible, but not with a first-time or one-time client. Instead, over a course of massage therapy, monitor the client's response to massage and chemotherapy. If the response is favorable, it might be possible to advance the pressure in small increments, and over limited areas of the body, reaching a more moderate or medium-level pressure over time. Deep pressure is usually poorly tolerated and is inappropriate for most people during chemotherapy, and in the months of recovery after chemotherapy.

Pressure is important to adjust, but so are other massage elements: slow the speed, use even rhythms, and use gentle transitions when shifting between techniques, positions, and areas of focus. Avoid drag on the tissues in the form of friction. Use unscented lotions or oils.

Interview Questions For Clients In Chemotherapy
Massage therapists working with people in chemotherapy ask certain questions of their clients to determine how to work with them. Following are some of the most important questions.

1. When do you have your treatment and how often?

2. How does it affect you?

3. What has your energy level been like? Your activity and movement level, day to day and week to week? How well do you tolerate activity?

4. How are your blood counts? (Ask before each session.) Has chemotherapy affected your blood counts at all?
- Are there any effects on blood clotting? Do you have any bruising or bleeding?
- Are your white cells affected? Are you vulnerable to infection?
- Are your red cells affected? Are you anemic?

5. Has chemotherapy affected your gastrointestinal tract at all? In what ways?

6. How has chemotherapy affected your skin?

7. (For hair loss) Would you like me to include your head/scalp in the massage? If so, how would you like me to massage it?

8. Do you have any numbness, pain, or other sensation changes? If so, where?

9. Any effects on other neurologic functions or processes like brain fog, trouble with memory, etc.?

10. Do you have a port or other medical device? If so, where?

11. (For clients not currently in chemotherapy, but with a history of it) Do you experience any lingering effects of chemotherapy?

Timing.
The first two interview questions are general, overall questions about chemotherapy. They can be used to schedule appointments with the client's chemotherapy cycles in mind. Nausea often peaks during the few days following chemotherapy. Blood counts can drop to their lowest, mid-cycle. No matter how long the cycle is, the first half of a chemotherapy cycle is a time to work especially gently.

The second half of the cycle may look a bit different. Most people feel their best right before a chemotherapy treatment, having had time to recover from the last one. At this time, nausea levels are often at their lowest, and blood cell counts are typically recovering. Since this is the time when people might feel the strongest, clients are least likely to miss appointments during this window. As the next chemotherapy approaches, it can also be a time that is fraught with anxiety, so it is a good time for massage.

Note that side effects can worsen with each cycle, as the effects of chemotherapy are cumulative over time. This overall trend may temper the highs of each cycle and lower the lows.

Chemotherapy can cause profound fatigue, whether anemia is present or not. Ask question 3 and follow-up questions about activity and energy to get a sense of this, as clients' activity tolerance may give a suggestion of their massage tolerance. Typically, a client's energy level can change from week to week, even day to day, so do not be too ambitious. Moreover, avoid spa treatments or massage techniques that are thought to have a detoxifying effect. Avoid, as well, treatments that include strong exfoliation. These approaches may be too taxing for someone who is dealing with strong medication. Again, your intent should be to support the client's body, not make another demand on it.

Blood counts.
It is a good idea to ask some version of question 4 at each session, since counts can change quickly. Bone marrow suppression is an ongoing reality or possibility during chemotherapy. If the client's counts are affected, remember that low platelets (thrombocytopenia) indicate less pressure be used overall, because of easy bruising and bleeding, and poor clotting. Appropriate pressures may range from moderate (when platelets are slightly low) to extremely gentle. When platelets are severely low, oncology massage educator Gayle MacDonald describes this work with clients as "massaging a ripe peach." Plenty of extra massage lotion or oil is applied to minimize drag on the skin. Work in collaboration with the client's health-care team is strongly recommended in order to determine whether light or heavy lotioning is recommended.

Low white blood cell counts (neutropenia) call for careful infection control. Standard precautions for infection control are supplemented with additional neutropenic precautions. Be certain that everything in contact with the client-- door handles, linens, oil bottle, surfaces on which the oil rests--is clean and sanitized. Individuals may even need to steer clear of plants or fresh flowers in order to avoid contact with microbes that they carry. In general, when patients are neutropenic, they do not go out a lot, and massage is performed in the client's home. If this is planned, ask the client what additional precautions are necessary for home visits. The client will likely have guidelines passed along by a nurse.

When working with anyone in cancer treatment, not just chemotherapy, it is a good time to monitor your own health and offer clients the chance to reschedule without penalty if you have symptoms that could indicate a cold, or gastrointestinal or skin infection. Even sniffles can be an issue, so it's important to notify your client if they occur. Do this, too, if you have had a recent vaccination with live virus.

Low red blood cell counts (anemia) indicate adjustments for dizziness, fatigue, and cold intolerance. A slow rise from the massage table is a good idea, as are easy transitions in position. Cold intolerance obviously calls for good ambient temperatures and extra draping. A gentle overall session is in order.

Other considerations.
Question 5 addresses the possibilities of constipation, diarrhea, nausea, and vomiting. The last three challenges obviously call for easy bathroom access, and the possible need for a client to wrap up quickly in a robe or linen in order to make it to the bathroom in time. These side effects also call for slow massage speeds, gentle pressure, and even, predictable rhythms. Likewise, joint movement should be limited. Avoid using scented lubricants or aromas with a client who has nausea. A wastebasket or other vessel is useful to have in case the client experiences vomiting. If this occurs, wear gloves while handling it and any other cleanup.

One might wonder how realistic this scenario is, and whether people who are this sick are likely to make it out to a massage session. While it's true that people try to stay home when symptoms are strongest, many people have to, or choose to, work and function through chemotherapy, and are out and about receiving massage. Home visits may be well received, as well.

If constipation is present, abdominal massage may be helpful; however, limit pressure to light lotioning on the abdomen if any abdominal tenderness is present, or if there has been no bowel movement in 72 hours. If this is the case, refer the client to his or her physician. For people in cancer treatment, there can be other factors that contraindicate deeper abdominal work, so keeping your touch light and holding the area with soft hands can be just as effective.

Ask question 6 to get a sense of whether the massage should be adjusted in response to skin inflammation, chapping, inflammation, peeling, or rash. All of the usual common sense massage adjustments apply. Avoid contact with open lesions. Avoid aggravating inflammation. If the client has lost hair due to chemotherapy, then question 7 provides a neutral, sensitive way of asking how you should massage it, with an opening for the client to remove any headwear or wig, or to leave it on. If it remains on, lubricant is usually avoided in the area because wigs and headwear can be expensive or inconvenient to wash. Massage the area with dry hands unless instructed otherwise.

Question 8 is targeted to peripheral neuropathy. If the client has neuropathy with pain or burning, then joint movement and pressure will obviously need to be limited in the area in order to avoid aggravating it. On the other hand, if the client presents with numbness or impaired sensation in the hands or feet, then pressure and joint movement should be gentle because normal feedback is absent, and the client can't tell you if something hurts and tissue may be injured. Also, inspect the skin (especially on the feet) for any foreign bodies or open skin. Sores can develop when pebbles or other objects in the shoe go unnoticed. Bring this to the client's attention and avoid contact or pressure at the area.

If clients experience brain fog (question 9) or seem to exhibit signs--forgetting appointments, repeating or contradicting themselves, lack of focus--consider making reminder calls before appointments. Take time with scheduling, and repeat important information and interview questions if needed.

Try not to "over-identify" with a client with brain fog--"I forget things all the time!" or "That sounds just like menopause!" Chances are that an occasional minor memory lapse does not compare to the ongoing, relentless, and terrifying experience of brain fog, and your friendly attempts to identify with the problem may seem dismissive.

Question 10 about a port or other medical device is important for anyone in cancer treatment. For a client with a port, you might need to modify or avoid the prone position. Using a couple of hand towels as padding around a port, creating a depression or nest, may be comfortable for some people. Other people barely notice their port and have no problem lying in any position. Steer several inches clear of the port with massage pressure, as it is larger than it appears.

While working with a client in active cancer treatment, communication with the client's physician is strongly recommended. This could take the form of physician permission for massage, a request for input into the massage design, or simply a physician acknowledgement of the massage care plan. The simple permission slip approach may be too general, and the physician may not know what kind of massage he or she is signing off on. Specific physician communication is more useful.

Later Effects of Chemotherapy
Question 11 addresses the reality that it can take a long time to recover from chemotherapy. Massage adaptations may be necessary even after it is complete. There is a common observation: "It can take a year to recover from cancer treatment." Respect this, and start gently; even if a client is 10 months out of major treatment, he might still be getting his strength back. Even though his counts are fine, his fatigue may be debilitating. On the other hand, treatment that ended 18 months ago might be barely noticeable, and the client is now playing basketball regularly. Also, recall that some neurological effects of chemotherapy--brain fog and peripheral neuropathy--may linger indefinitely.

Cancer can be one of the most medically complex conditions to manage in a massage therapy practice. There are many factors to consider in planning massage for someone with active cancer, in cancer treatment, and even in the weeks, months, and years following treatment. It is important for massage therapists to consider not just chemotherapy, but also radiation therapy, surgery, the health of the lymphatic system posttreatment, and many other factors. To work safely with people with cancer and cancer histories, massage therapists have a professional responsibility: at the very least, to delve into the oncology massage literature. Advanced training in oncology massage is strongly recommended.

Possible Massage Benefits
Clients and therapists tell countless stories of the benefits of massage during cancer treatment and life beyond treatment. Massage may provide comfort during chemotherapy and may help heal a poor body image after treatment. Symptoms and side effects--anxiety, depression, fatigue, nausea, and pain--are major concerns in cancer care. Massage may have a direct effect on any of these, providing welcome relief to a client and the people who comprise her support system. Moreover, the relaxation effects of massage might promote sleep, which can make other side effects and symptoms more manageable.

While there is some research on massage and chemotherapy, the scientific literature does not yet show overwhelming evidence in support of the benefits. As the body of evidence grows, I continue to keep a bibliography of research on my website, and the Society for Oncology Massage (www.s4om.org) summarizes research as it surfaces.

The Companionship of Massage
Even without a clear evidence base, it is fair to say that the companionship of massage therapy has the potential to ease a host of psychosocial problems that arise during any life-threatening health crisis. Among them are isolation, fear, grief, and stigmatization. Chemotherapy can be a difficult, long leg of the cancer journey, and clients report that skilled massage can do wonders to ease their experience.

Tracy Walton, LMT, MS, is a researcher, writer, award-winning educator, and specialist in massage therapy and cancer care. She is a dynamic voice for the power of touch and appears in the film Touch, Caring, and Cancer, an inspiring instructional program for care partners. She taught physiology and pathology at the Muscular Therapy Institute (now Cortiva Institute-Boston) for 13 years. She has devoted much of her work to massage therapy for medically complex client presentations. She helps massage therapists simplify massage contraindications, ease the interviewing process, deepen clinical reasoning skills, and expand their client base. For more information, visit www.tracywalton.com.




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