By Dietrich W. Miesler, MA, CMT
Originally published in Massage Bodywork magazine, February/March 2002.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.
The incidence of Parkinson's disease in the United States is estimated at 1 million, with an additional 50,000 patients being diagnosed every year. While it is generally considered a disease of those between 50 and 79 years of age, incidence below the age of 40 is rapidly increasing and epidemiologists suspect environmental influences are playing a part in this phenomenon.1
Noting that Parkinson's is still essentially a disease of aging, the likelihood of caucasians coming down with the disease is 2.5 percent. The figures for African American and Asian populations are somewhat lower.2
Parkinson's disease is a neurological movement disorder that affects the substantia nigra, a small area in the basil ganglia. The substantia nigra is the key to the coordination of muscle movements by being the only local source of dopamine. While dopamine is produced throughout the body, dopamine from sources other than the substantia nigra cannot penetrate the blood-brain barrier and therefore is useless for this condition.
The major clinical manifestations of Parkinson's disease are tremors, muscle rigidity, akinesia (temporary inability to move), dyskinesia (inability to execute specific voluntary movements at will) and loss of postural reflexes.
Parkinson's has so far proven to be incurable, but there are drug treatments available which do a good job of dealing with the major somatic symptoms. However, these drugs are not without side effects and as time goes on, they lose their effectiveness and have to be discontinued. The long-term success of drug treatment depends, to quite a degree, on the constant, diligent cooperation with a physician who is able to adjust medications to the changing needs of the patient.3
Against this background comes our attempt to incorporate massage into the treatment protocol of the somatic symptoms of Parkinson's disease with a totally new concept -- the rationale that relentlessly increasing stiffness and tremors lead to muscle exhaustion, similar to that found in athletic endeavors. The available oxygen is insufficient for the amount of work the trembling and permanently contracting muscles need in order to stay in good repair.
The stresses put on the Parkinson patient's body are similar to stresses endured as the result of sporting activities. The big difference, however, is that exhausting sporting events are typically followed by long periods of rest and relaxation, whereas the poor musculature of the Parkinson's patient never has any rest period, and hence suffers structural changes which make it palpably different.4
Geriatric massage, with its manifold effects on the body is, of course, the perfect medium to keep muscles soft and pliable (i.e., in five minutes, the long strokes of Swedish massage carry 10 times the amount of blood to the massaged muscle as arrives naturally during a 15-minute rest5
). The effect is most noticeable where there is a lot of cleansing and nourishing going on, as is in the case of the Parkinson's patient who is in the clutches of a nervous system gone haywire.
The effect on the release of neurotransmitters by massage is likewise enormous and may be responsible for the production of endorphins with their calming influence. The question that interests me is, are they still noticed by a patient who is under the powerful spell of antianxiety drugs such as Xanax and Prozac which often take the patient's mind out of circulation and prevent them from taking charge of their own coping process? The well-documented stress reduction capabilities of massage should at least be given a fair chance if there is a competent massage therapist, a willing patient and a physician who is curious enough to stand by and supervise the experimental withdrawal of the antidepressant medication.6
There is still one more factor calling for serious scrutiny, an observation a number of my colleagues, students and myself have made repeatedly. Massage seems to enhance the utilization of various L-dopa combinations that are being used with good success. If this is born out through careful research, then massage could really become an important factor in the treatment protocol, as it could conceivably prolong the overall effectiveness of medications for years beyond their present usefulness. Just imagine adding years of useful life to people who now feel doomed by their diagnosis and their failing bodies.Implications for Massage Practitioners
If there is any question in your mind why Parkinson's is such an important field for massage therapy, you just have to read the list of physical changes the person with the disease can expect, despite drug treatments. The picture, as painted in the authoritative Merck Manual of Geriatrics
, is not very pretty. The following chapter is reprinted by permission of the publishers. Symptoms and Signs
The disease begins insidiously; any of its cardinal manifestations may appear alone or in combination. Tremor, usually in one or sometimes in both hands, involving the fingers in a pill-rolling motion, is the most common initial symptom. The tremor is present at rest, accentuated by sustentation, but decreased during active movements and eliminated by sleep. It is rhythmic, alternatingly affecting flexor and extender muscles and may involve upper and lower limbs, mouth or head. This is often followed by stiffness of the limbs, generalized slowing of movements, and inability to carry out normal and routine daily functions with ease.
Muscular rigidity is readily evident on passive movement of a joint and is manifested by a series of interrupted jerks (cogwheel phenomenon), rather than a smooth-flowing easy motion. Bradykinesia is the tendency to slowness in the initiation of movement and sudden unexpected arrest of volitional movement while carrying out purposeful actions. The Parkinsonian patient appears disinclined to move, and in the middle of performing a routine function, suddenly becomes "frozen" and unable to follow through the sequence of motions necessary to complete the action. This is especially evident in writing or feeding and can be striking when, in attempting to walk, the patient finds that their feet are suddenly "frozen to the ground." Rapid, alternating movements of the extremities are slowed. As the disease progresses, the face becomes "mask-like," with failure to express emotional feeling and with diminished eye blinking; but with ready induction of blepharospasm a twitching or spasmodic contraction of the orbicularis oculi muscle when the frontalis muscle is tapped (Meyerson's sign).
The body becomes stooped, the gait becomes shuffled, there is a loss of arm swing, and the patient is unable to readily gain and maintain erect posture. Posture abnormalities are evident in the erect and sitting positions. The patient has the tendency to let the head fall forward on the trunk and the body tends to fall forward or backward when the patient is seated on a stool. When pushed from in front (propulsion) or from behind (retropulsion) in the erect position, the patient falls, and no attempt is made to stop the fall either by a step or by movement of the arms. Deformities of the trunk, hands and feet tend to occur. Kyphotic deformity of the spine, causing a stooped posture, is a hallmark. Ulnar deviation of the hands, flexion contracture of the fingers, or an equinovarus (walking without touching the ground with the heels and with the soles turned inward) posture of the feet can be found.
Speech becomes slow and monotonous. The patient tends to drool. The skin takes on an oily quality, and there is the tendency to seborrheic dermatitis. Mood abnormalities, usually in the form of depression and anxiety, are frequent. In some instances, they may be the heralding symptoms of the disorder, while in others, they are a reaction of the slowing of motor activity. Although intellectual impairment does occur, controversy exists as to whether it is intrinsically part of the disease or related to associated dysfunction in this age group. Although Paralysis Agitans is invariably progressive, the rate at which symptoms develop and disability ensues is extremely variable. In some instances, the disease is rapidly progressive and patients become disabled within five years of the onset. More often, a slower, more protracted course of evolution of symptoms occurs and patients remain functional for extended periods of time.7
The plethora of potential defects awaiting a Parkinson's patient does explain the bouts with depression and hopelessness they are also prone to experience. The prevalent attitude of helpless resignation to the inevitable is explainable by the fact that Parkinson's disease typically strikes people who were preparing for retirement or who just became adjusted to the fact they had retired, that their fighting days were over, and that medical emphasis is on palliative treatment, rather than on helping the patient to marshal all inner resources to not give up easily. A client of mine, diagnosed nearly four years ago with early Parkinson's syndrome, told me that according to his observations, his walking problems seemed to originate not so much from faulty nerve transmission, but from the fact that his rigidifying leg muscles couldn't conduct movements as directed by his brain. He believes that maintaining pliability of the musculature goes a long way toward maintaining proper leg movements. When the disease was confirmed by my client's physician, he puzzled the good man when he embarked on a walking and light weight training program (he was then close to 70 years old) and did shed a few extra pounds in the process. He was on minimal medication with heavy vitamin supplementation. In addition, he had two 30-minute massages a week, chiefly on his feet and legs. My client continues to feel fine even now after four years.
There is already a lot of theoretical and practical information on the effects of massage which has been developed empirically, as well as scientifically. By involving ourselves in something as serious as the treatment of the somatic symptoms of Parkinsonism we must not only use all available resources, but we should also strive to add to the existing body of empirical knowledge. Naturally, you can disregard this when massaging clients with Parkinsonism, turn on your intuitiveness and if you use common sense in your work, you will give them some measure of relief. Time, skill and energy, as well as your clients' health potential, not to mention their money, would be better utilized by directing your efforts toward the Parkinson's symptoms: muscle rigidity, tremor and depression.
Muscle rigidity is caused by the lack of the neurotransmitter "dopamine" in the brain which is essential for coordination of the complex muscle systems required for every intentional movement. The lack of coordination can be expressed in different ways. Most often, however, it is noticeable in gait problems. As long as a person can get around unaided they are not helpless; that's why to us, the most important muscles are those of the lower limbs. By easing their rigidity, we can help our clients to normalize their gait, to improve their sense of balance, to minimize the problems often encountered when trying to rise from a sitting position or when getting out of a car. When coupled with a sensible exercise program to strengthen specific muscles, this phase of massage is possibly the most important. Depending on how long the client has been suffering from the disease, there may be obvious improvement or at least no further decline. The rationale is that by restoring physiological health to the muscles, they will be better able to respond to the improper signals they receive from the nervous system.Hands-on Approaches with Supine Client
Once the muscle balance is out of control, we find indications that the flexors, being the stronger of the flexor/extensor units, take over (similar to spastic paralysis after a stroke). Many of the postural symptoms described in the excerpt from the Merck Manual of Geriatrics attest to that. That means it is important to do range of motion (ROM) exercises. Of course, you do not just grab a leg and shake or twist the heck out of it, but you do have to remember that joints are moved by muscles; hence, before you can do any real successful ROM, you have to relax the muscles which control the respective joint(s). Another thing you have to remember is to be careful. If you feel resistance, don't fight it, coax it. The secret is in the sensitivity of your hands that have to pick up if the move is uncomfortable to your client or forced, and then search for a better way to do it. Don't do ROM on people with joint replacements unless you have been instructed what their range limitations are.
When it comes to feet, especially in the case of equinovarus, you should try a little restorative work. Make sure you relax the gastrocnemius and soleus (before you attempt to put a stretch on the tendon) by gently plantar-flexing the foot while the knee is still bent. Play with the tendon; stretch, relax, stretch, relax, and finish this phase by having your client push against your resisting hand. Also, do not forget to work the sole and the metatarsal joints that bear the brunt of walking when the heel is not touching the ground. Lastly, work the ankle joints and the tarsals that are ingeniously designed to allow lateral and medial flexion.
The neck and shoulder region usually always require attention. The musculature involved in the classic Parkinsonian who exhibits a slumped forward posture with the head bent, shoulders rounded, and arms hanging down to both sides of the body with slightly cocked elbows, is complicated to assess. The main forces responsible for the bent head syndrome are the contraction of the three scaleni and the weakening of sternocleidomastoidus (SCM). For the round back, the contraction of the two pectoralis muscles and the weakening of the complex musculature of the sacrospinalis are the culprits.
Unfortunately (for massage purposes), the origins and most of the body of the scaleni are fairly deep, embedded in a complex network of blood vessels, nerves and connective tissue, covered by the upper trapezius. As they insert in the first rib underneath the clavicle or the second rib, respectively, covered by pectoralis major, the insertions are also hard to palpate. Work on the SCM is also difficult as the muscle runs across major blood vessels and nerves and in close proximity to the thyroid gland. At least SCM is a surface muscle and the insertions at the mastoid bone and occipitus, and the origins at manubrium and clavicle, are accessible.
I suggest approaching neck massage with Parkinsonian clients chiefly with ROM techniques, loosening up the muscles of the neck as a unit. If your client needs a pillow under the head, I suggest taking it out during the neck procedure and "forgetting" to put it back when you are done. In most cases, the head will fall back and rest comfortably on the table. To strengthen the spine and head extenders, do some resistance exercises with your client.
The shoulders are pulled forward by pectoralis major and minor, stretching and thereby weakening the two rhomboids. With petrissage and friction, pectoralis can usually be relaxed enough to allow ROM of the shoulder which is very important. By pushing the shoulder toward the spine, you foreshorten the upper trapezius, thereby relaxing it and making it easier to massage successfully.
Arms should be massaged, similar to legs and feet, with the techniques I recommend for geriatric clients. This could make the muscles more supple. It will not, however, restore the arm swing that is initiated instinctively when walking to keep balance. We all perfected the alternating use of upper and lower limbs when we learned to crawl as babies. With the spontaneous nerve impulses apparently gone, it would take a conscious act of will on the part of the client to reinstitute arm swing. According to generally accepted beliefs, reinstituting arm swing just would not work with Parkinson's patients, to which my already mentioned client replied, "....and according to aerodynamic engineers, bumble bees can't fly." Of course, his arm swing is not yet impaired. So, he plans to buy a walking machine. I'll keep you posted.
From the specific, let's now go to some concluding general comments. Parkinson's is a strange disease; but since the majority of symptoms involve musculature, it would be surprising if bodyworkers were not attracted to the problems in order to help the afflicted ease their burden. How far one can go depends on many factors -- the age of the client, the stage of the disease, the client's willingness to work on it, the general physical and mental state, the cooperation of the client's family, the support of the physician, your skill and resourcefulness, and many other factors which will influence the final outcome.
What techniques to use is largely determined by the therapist's training and willingness to keep learning. My own background is in Swedish massage, but in decades of working with all kinds of people and attending all kinds of classes and workshops, I realized that Swedish, while enormously effective, is not the "be all and end all." Other techniques which are extremely helpful when working with elderly clients include Trager, lymphatic drainage, energy work, reflexology, trigger point and neuromuscular work, to name just a few. The main thing is that you know what specific result you want to achieve, and you choose your technique accordingly. If the result is not to your liking, try another way.
Beyond the mechanical part of our work, you should always be aware that you are working with suffering human beings in the attempt to ease their burden. That requires a lot of sensitivity toward your client's emotional and basic human needs. Take one step at a time and don't contribute to your client's discouragement by over-promising. When working on a condition such as Parkinson's, therapist and client should both be ready for surprises. Whatever you do, keep in touch with the client's physician and please check back with me with the good news, and with the bad news, too. If you have questions, I will try to answer them. Don't forget to watch if your work has any influence on the utilization of medications. Good luck and much success.Dietrich Miesler is the former director of Day-Break Geriatric Massage Project. He resigned his position June 15, 2000, but that does not mean he has gone home to tend his garden. Miesler will stay involved with Geriatric Massage and will maintain his column here. For any questions or comments relative to this article or the topic of geriatric massage, feel free to consult him: 707/824-0411. Issues pertaining to Day-Break now rest in the capable hands of Dr. Sharon Puszko, former dean of education for Day-Break who now assumes the position of director. Reach Puszko at 317/722-9896. The distribution of Day-Break products is now handled by Michelle Phillips of MRP Associates, 954/578-5042.References