By Dietrich W. Miesler, MA, CMT
Originally published in Massage Bodywork magazine, October/November 2000.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.
EDRF. It stands for Endothelium Derived Relaxing Factor. I first made its acquaintance in 1978 when I was summoned by the neighbor of an 18-year-old client, John. This client was an incomplete quadriplegic as the consequence of a minor car accident; John's condition required my thrice-weekly presence. After the neighbor saw the tremendous progress John made, for which I received completely unjustified credit, she chose me to save her father's legs from amputation. Despite my protestations, she implored me to at least meet her father. Reluctantly I agreed. Well, why not? I had the time, her father lived close to the university I was attending, I was a pretty good technician and besides, I still had to pass the interview with the man's doctor. I found it kind of ludicrous that I, a relative novice in the field of massage, should be working with a 79-year-old gentleman in order to save his legs; limbs which had been doomed by his highly reputed Stanford physician. What could I possibly know that the doctor didn't? Still, a tentative date for the procedure -- a double amputation above the knee -- had been set for January 1979.Case 1
Karl, the client, insisted on the delay from October to January so he could enjoy the holiday season with his family for one last time with legs intact. Due to heart and lung problems, there was some doubt if Karl would even survive the surgery. The doctor agreed to his ailing patient's request.
In October I went to see Karl and his legs for the first time. It was a ghastly sight. Both legs, from the knees down to the feet, were black and blue; there was not a trace of a popliteal or foot pulse in evidence. On the emaciated calves there was hardly any muscle left. The only "signs of life" were two ulcers which had formed underneath the nails of the great toes, each oozing a foul-smelling puss. I was shaken by the possibility that I might not be able do what I was expected to do.
I put my trust in the doctor and called him; Karl and his wife sat a few feet away, watching my every gesture and expression. They, however, had talked with the doctor beforehand. I asked him all the right questions and mentioned my lack of experience. "Oh you just give him a light Swedish massage," said the doctor. "And Karl's daughter tells me you are really helping that quadriplegic neighbor boy of hers."
I asked the doctor about the dangers of blood clots. His answer: "Oh, don't worry about blood clots. What do you think can happen in surgery?" I concluded by asking him sheepishly if he thought I could help Karl's condition. This is where I heard the "Doctor Mantra" for the first time: "If the old gent likes your massage you can go on and do your work. But, of course, you can't change his condition."
When I heard this last phrase, "you can't change his condition," it occurred to me for the first time that making a test case of Karl would not be such a bad idea. This "I'll show them" attitude is also the reason why it sometimes helps if you are a virtual layman. I did not know then whether it was possible to save doomed legs by massage. Now, I know that it works.
The biggest challenge was the recognition that I had no idea how to proceed. I had to use my head to work out the protocol. The only thing clear in my mind was that I would not limit my work to the doctor's idea of just "keeping the old gent happy."
The secret with massage is not that you touch every square inch of skin surface, but that you determine what you want your touch to accomplish. What is completely forgotten is the fact that when we massage a body, we really do not work the musculature; instead we communicate with the nervous system via the muscular system. The problem in Karl's case was to position the leg muscles such that they were completely relaxed, then to send signals to the brain to leave the muscles relaxed, regardless of what else you did. Two hybrid techniques came about this way - "butterfly tapotement" and "fluffing." They both were perfect for draining blood from the legs. By putting the lower legs in an upright position allows gravity to help the process.
But how could these temporary measures have brought about a permanent improvement of the condition, in fact causing Karl's doctor to cancel the amputation entirely, and allowing the client to live with his limbs until his death several years later? That was the big question that engaged me for almost 20 years: How did I work 6-8 minutes on each leg, every other day, and in the end -- after eight months -- have restore pulse in both the popliteus and the foot. How could this little effort bring about a major change in the physiological state of the body?Case 2
An 82-year-old German woman, Maria, visited her son for what she thought was the last time. She was convinced she would not be able to visit again once her legs were amputated. Her case, like Karl's, did not shed light on the burning question either: What feature of the protocol I had developed and used prophylactically on many clients with suspected and diagnosed Peripheral Vascular Disease caused change in the circulatory system?
Maria's problem was different from any of the others I had treated with the protocol. She had an inguinal shunt which performed beautifully for about 10 years, but shunts are often used on people who are in their 70s and are not expected to outlive the usefulness of the shunt. If the shunt fails, it often leads to amputations.
Maria's son persuaded her doctor in Germany to permit the massages for the five months she was to remain in this country; she then continued treatment in Germany with a local therapist who used the video faithfully. Since then she has been back to the United States two or three times for extended stays, without her cane, feeling better than ever and walking much more securely than before we began the treatments. The end result was as expected. The blood flow through her legs was corrected. But, as always, my burning question remained. Why can't anyone tell me, what is going on in the body?
Enter Dr. Stover, an unusual man. He is a well-known orthopedic surgeon in northwest New Jersey who has a financial interest in a beautiful nursing home. He is semi-retired and showed a keen interest in the use of massage in the care of the elderly.
I'm proud that a man of this stature made a real effort to hunt me down. We spoke for a couple of hours, mostly about application of massage in the treatment of the elderly patient, especially in a nursing home setting. He had an astute memory, and he quizzed me about several articles of mine through which he had learned of me.
When my turn to ask questions came, I asked him how it is possible that short massages of 6-8 minutes, on a regular basis, over several months, can have such a profound effect as permanently reversing Peripheral Vascular Disease.
He answered: "I am not aware that anyone has done it, but there is a very simple explanation for the possibility. Two British researchers discovered a strange phenomenon inside the blood vessels that they temporarily called EDRF - Endothelium Derived Relaxing Factor. It later turned out to be nitric oxide (NO), a well-known, powerful vasodilator. The strange thing is, that EDRF reacts to the shear effect of the muscles that surround the reacting blood vessel. In other words, activity in the musculature triggers release of the nerve transmitter; this is an emergency measure to make sure enough blood is available when the muscles are working. Since the EDRF has a short half life, there is no danger of great amounts of EDRF accumulating. By the way," Dr. Stover concluded, "there is at least one medical device on the market which uses this principle to support and monitor post-surgical blood circulation. I am not surprised at all that your success with massage in the case of threatening amputation can be facilitated by proper manipulation of the musculature."
Dr. Stover went on to share a study1
with me from the division of Orthopaedic Surgery at Duke University Medical Center in Durham, N.C., that studied the effect of intermittent pneumatic compression (IPC) on the microcirculation of distant skeletal muscle. An effective means of preventing deep vein thrombosis clinically, IPC has been proven to cause both systemic and hemodynamic changes, but the mechanism is still not clear. This study asked if IPC of the lower limb exerts an effect at the level of the microcirculation in distant skeletal muscle.
Research rats where divided into two groups: the experimental group had two IPC devices attached to both hind legs to deliver pressure, while the sham group had two IPC devices, but without compression.
As the compression devices pumped 5 seconds on, 25 seconds off for one hour, the dilation of the blood vessels began almost immediately with the steepest vessel dilation occurring after the first 10 minutes, continuing to rise until 30 minutes and then slowly diminishing. The vasodilatory effect was significant for every point during compression and for the first 10 minutes after termination of IPC.
By increasing venous blood flow velocity, IPC creates stress on the vessel wall which may induce the release of nitric oxide (or EDRF) from vascular endothelial cells, reducing systemic dilation of vessels.
In conclusion, the fact that IPC improves microcirculation of distant skeletal muscle may relate to the mechanism of IPC preventing deep vein thrombosis, and therefore may be clinically useful in reducing venous stasis and tissue edema after surgical procedures.
In addition, the findings of the research add another page of justifications to my belief that the results so far have not been flukes, but rather that we are on the right path with our claim that Day-Break's Geriatric Massage Project has two star clients whose legs were saved from imminent amputations with our science-based process. 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.
The video "Massaging Legs to Increase Blood Circulation" is available from MRP Associates, 44660 N.W. 99th Ave., Sunrise, FL 33351; 954-578-5055.
What Is a Shunt?
Shunts are used to circumvent obstructions in arteries or other hose-like structures within the body. In the case of Maria, a shunt was necessary to supply enough blood to the legs. Her problem was apparently that enough blood was supplied, as indicated by her deep black string-like network of arteries visible on both legs, but the venous system seemed to be overstressed, unable to keep the blood flow sufficient. Apparently the techniques we used were able to affect the venous circulation sufficiently.
Defining the Procedures
Butterfly Tapotement is a gentle move that works beautifully in loosening up hardened muscle structures in the long muscles, especially of legs. It is executed with the client in the prone position, legs bent at the knees and resting against the chest of the therapist. By loosely drumming with the fingertips on the calf muscles, beginning at the ankles and slowly moving toward the popliteal area and repeating it several times, you can improve the blood flow, especially in the microcirculation which is frequently responsible for peripheral vascular disease. The treatment should be repeated two to three times per week. Reduce frequency once you see and feel the results.
Fluffing is a hybrid move that consists of a combination of effleurage and petrissage. It is the ideal follow-up move after butterfly tapotement because it isn't much stronger. It starts out with a number of simple gentle effleurage strokes to which you stop every inch for a relatively short squeeze. The movement is toward the heart. If you do the fluffing after the butterfly tapotement you do not have to change the client's position. If you do it in connection with, for instance, the NIDDM protocol, you have the client in the supine position with the knee bent, the therapist supporting the knee with one hand, to relieve the client from having to hold it. In this position, the hand again has to move toward the heart.