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Working with Challenging Skin
Using Tender Touch in Geriatric Clients

By Sharon Puszko and Jane Keegan

Originally published in Massage Bodywork magazine, August/September 2003.
Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.


The nature of massage therapy means practitioners are constantly in contact with the client's skin, the largest and heaviest organ of the body. Accounting for 16 percent of our total body weight, it is invaluable as it protects everything underneath it from disease, chemicals, bacteria, injury and the elements.

But, as we age, the amount of collagen and elastic fibers in our skin diminishes, resulting in wrinkles and pigmentation changes. With maturity, our skin is also affected by the reduction of muscle mass, slower nerve impulse transmission and the loss of adipose tissue, allowing the skin to thin and tear more easily.

It is important for massage therapists to recognize and be sensitive to the changing nature and condition of a client's skin. Anyone can be affected by a skin disorder, but these issues are even more important for geriatric clients. Let's look at four common skin disorders, their visible symptoms and considerations to keep in mind when practicing massage therapy.

Cellulitis is a bacterial infection most commonly found in the lower extremities and may affect the face, limbs and legs. Cellulitis may appear after an injury, but it's also been diagnosed in infants and adults over the age of 30 who have recently recovered from strep throat. Symptoms include inflammation of local lymph nodes, fever and flu-like symptoms. The affected area is tender and hot to the touch.

There are varying opinions on treating a patient who has cellulitis. According to Clinical Pathology for the Professional Bodyworker, it is appropriate to perform massage therapy as long as the area infected is avoided, as massage could spread the infection and cause inflammation.1 In addition, the massage table must be thoroughly disinfected afterwards to prevent the spread of infection.

Decubitus ulcers forms when epidermal cells and deeper skin tissues die due to a lack of blood supply. Decubitus ulcers are found on any area that lies just over a bone and receives prolonged pressure from an object (hence the common name, "bedsores"). According to Clinical Pathology for the Professional Bodyworker, "Common locations include the lateral malleolus, ischial tuberosity, greater trocanter, posterior sacrum and coccyx."2 Initial signs of a decubitus ulcer include redness that doesn't go away, swelling of the skin and the formation of one or more blisters. On dark skin, these areas will appear black or grey. These signs are considered a Stage I ulcer. In extreme cases (Stage IV), there is extensive destruction of the skin tissue, known as necrosis, and possible damage to muscle and bone.

Massage is not recommended on or near the area of the ulcer as research has proven it can cause injury and may decrease blood flow to the area. However, massage around the area of the ulcer may indirectly help circulation there, and is therefore recommended. You may also want to recommend your client drink plenty of water, keep the ulcer as dry as possible and eat plenty of protein.3

Scleroderma causes inflammation and hardening of the connective tissues of the skin, blood vessels, muscles and other organs. It is an autoimmune disorder and can affect females between the ages of 30 and 50. Symptoms include thickened skin, stiffness, swelling in the affected tissues, decreased range of motion and generalized swelling.

In conjunction with other therapies, massage has been used successfully to treat joint stiffness and muscle problems. Research suggests massage may be useful in improving circulation and preventing muscle distortion.4

Massage therapy client Karen Blyth started suffering from symptoms of scleroderma in 1996 at the age of 46. She tried massage therapy as a form of treatment. The following is her experience:

"I have and am still seeing a registered massage therapist regularly. She even came to my house twice a week to work on me when I came home from the hospital. The first time she worked on me, my skin was so hard she could barely move it. As she continued to work on me over a period of time, she could see my body change from stone to soft, supple skin. My massage therapist says my skin now feels normal and I only need to continue massage treatments when required. However, I intend to continue massage therapy on a monthly basis, as I feel it has been a large part of my therapy."5

Treatments should focus on softening the skin with cream or lotion, increasing circulation to the affected tissues through effleurage and petrissage, and reducing muscle spasm. Effleurage and lymphatic drainage strokes toward the heart can also reduce lower extremity edema. Applying heat before and after movement therapy helps relax muscles and joints.

Benign skin tumors such as oles and skin tags are frequently found on people. Moles are pigmented growths that can be flat or raised, and are not a contraindication for massage, movement or hydrotherapy. That being said, please be aware of the size, color and thickness of the mole. If any of these aspects should change, or if bleeding seems to have occurred, it could be a sign that the mole has become malignant. Skin tags are soft, small, flesh-colored or pigmented and seem to hang from a stem. They are usually located on the neck, groin or axillary region and are not a contraindication for massage either.


Health Hero
When working with the ill and elderly, the aging process and illness can cause the skin to tear and bruise easily. With this in mind, do not use modalities that have long stripping strokes or work deep into the tissue. Using lighter, fluffing strokes is effective in promoting circulation as well as being safe, comfortable and relaxing to the geriatric client.

The above mentioned skin conditions are four of the more common found in the geriatric client. Please note that while common to the elderly, these conditions can be found in any age group. And there are many, many other skin conditions. Some conditions may be a rash or an allergy to foods or dyes. Two recommended resources are Ruth Werner's A Massage Therapist's Guide to Pathology (Lippincott, Williams Wilkins: 1998) and Kalyani Premkumar's Pathology A to Z: A Handbook for Massage Therapists (Van Pub Books: 2000).

As massage therapists, we have the opportunity to observe our clients' skin in a way in which they do not. Through touch and sight we are able to detect changes our clients may overlook or, on the back for instance, may not be able to see. In this unique position, we have the opportunity to be our client's "health hero."

Remember, when in doubt consult the individual's primary physician for insight and permission.

Sharon Puszko, Ph.D., C.M.T., is director of the Day-Break Geriatric Massage Institute. For more information, she can be reached at 317/722-9896 or via e-mail at spuszko@juno.com. Jane Keegan, L.P.N., is a Day-Break instructor and massage therapist in Florida.


References
1. Newton, Don, M.A., D.C. Clinical Pathology for the Professional Bodyworker. Scappoose, Ore.: Simran Publications: 1998: p. 182, 184, 189, 192-194.
2. Ibid., 189.
3. Division of Rehabilitation. University of Illinois at Urbana Champagne: www.rehab.uiuc.edy/beckwith/patraining/skin_care.html
4. Health and Age: www.healthandage.com/html/res/com/ConsConditions/Sclerodemacc.html#MassagePT
5. Blyth, Karen. You can beat scleroderma. www.exboard.com.






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