By John Mramor
Originally published in Massage & Bodywork magazine, July/August 2010.
There is a growing body of research pertaining to the effects of various forms of foot massage—including reflexology—on anxiety, depression, immune system response, nausea, pain, and stress. A general review of the literature between the years 1999–2007 found that foot work is demonstrating significant outcomes within a broad spectrum of populations, from postsurgical patients to people with cancer to middle-aged women to hospitalized patients.1
This research is encouraging for hospice patients, who suffer not only from the aforementioned complaints, but also from an assortment of maladies, including symptoms from disease, side effects of medication, psychosocial/emotional issues, or spiritual angst. The two most prevalent complaints within the hospice community are anxiety and pain. These are typically the most unsettling and disturbing sensations across the multidimensional planes of existence, as this author’s 12-year, full-time, professional association with hospice continues to prove.
Applicable For A Broad Population
Created originally within a hospice environment, antianxiety foot massage should not be misconstrued as a treatment solely for the purpose of providing benefit to dying individuals. It is applicable to all settings and all populations, including people with physical/mental challenges and children. There are few contraindications, the most pronounced being classic skin issues pertinent to all manual therapies or a proclivity to being ticklish (although by adapting pressure and approach, this typically becomes a moot issue). Therefore, as you read on, please consider concluding a spa session with this technique, or establishing grounding during an energetic session, or gently awakening a client after a guided imagery session. I often blend this technique with other modalities, too, and adapt it for use on the face and head. It is perfect for use by those specializing in the psychological arts, especially as a link to the utilization of craniosacral or polarity therapies, as these are becoming increasingly popular with counselors, social workers, and psychologists.
Born Of Necessity
Antianxiety foot massage was born from a necessity to provide a means of calming the ever-heightening anxiety presented by a client with end-stage chronic obstructive pulmonary disease (COPD). It was near the beginning of my career when a woman with COPD was admitted to the facility in which I was working. One morning, at 3:00 a.m., she experienced an exacerbation of shortness of breath, which immediately increased her anxiety. Medication was minimally helpful. Remembering my recent admittance to the massage program and remembering my 24/7 policy, she informed the staff that perhaps the calming sensation of touch would, in some way, have a positive effect on her breathing.
Upon arrival, I found her not only extremely anxious, but agitated, as well. I engaged her with foot massage, sleepily thinking that of all modalities, a foot intervention would serve many purposes. First, it is noninvasive, far from the center of her true being. This was especially helpful since a touch relationship had not yet formed and, more importantly, since she was experiencing respiratory distress, staying away from the center of distress was psychologically the correct approach. Second, it was revealed during her intake interview that she had always enjoyed having her feet rubbed, since her career as a security guard was spent walking in heavy shoes. Third, I believed that a movement-oriented massage would have more impact than an energetic modality in this case, as it was believed she required something to distract her attention, and concentrate on. Finally, it simply seemed the right thing to do.
Prior to engaging her, I remembered how I had fallen asleep that very night. It occurred while listening to a CD recorded by a psychiatrist. The recording was based on hypnosis theory and utilized two stories told simultaneously, but separated in time. Why not try the same with my hands? Why not provide a hypnotic massage by moving the hands in somewhat identical patterns, but as if they were mimicking one another, like a musical canon or echo.
It worked perfectly that night, and as the weeks rolled by, this same client willingly offered comments as the procedure was developed. Fortunately, during that same period, a string of clients with COPD were admitted, thereby affording me a wealth of subjects with which to perfect the new technique. It has now been approximately 10 years since that initial experience and I still use antianxiety foot massage for client pain and anxiety today.
Theory Behind The Work
Antianxiety foot massage was inspired by Lloyd Glauberman’s pioneering use of Hypnoperipheral Processing, a form of dual induction sensory overload. Glauberman’s technique utilizes two stories that play simultaneously, one in each ear; the second story is delayed in time by approximately one minute or so. Initially, the person attempts to listen to both or tries to concentrate on just one, but fails as the logical part of the mind becomes overloaded, after which a deep state of relaxation ensues. It was the delayed overlapping and simultaneous delivery that inspired me to create a touch-related counterpart.
To induce hypnosis, overload techniques are often employed to confuse the mind. With these techniques, the key is to overload a person’s normal processing rate, thereby creating a level of confusion. The main intent is to disengage a person from willing herself to do anything, to disable her from having a fixed conscious process occurring, both of which usually limit trance development. The techniques used to promote disorientation can be temporal referents, external or internal spatial referents, surreal imagery, conceptual disorientation, and/or verbal overloading. Perhaps the most crucial element involves the delivery style. Special attention must be made to utilizing a style that is meaningful enough to simultaneously develop and maintain a person’s attention. The effectiveness of these techniques comes from the inability to let go of constant thinking.
Since touch has not traditionally been involved in producing a hypnotic-like state, it is interesting to consider what the mechanism of induction entails. Basically, the practitioner absorbs a person’s attention with the initial stroke sequence that culminates in the addition of the second hand, providing a similar pattern that is delayed in time, much like a musical canon or echo. Confusion is instilled by directing their attention to the changing patterns, always followed by the second hand. This plays with each brain hemisphere, dominant and nondominant. The delivery style maintains a slow, rhythmic pulse that must be captivating. This level of interest is enhanced by subtle and gradual changes in touch elements corresponding to area, texture, depth, intensity, speed, pathway, and temperature. The practitioner becomes a master in varying these in order to maintain attention. Music also assists in setting a tranquil tone, lending another element for distraction. However, the music must be spatially oriented with nondominant melodies and without beat emphasis.
Applying The Massage
Antianxiety foot massage consists of seven strokes. Each stroke is repeated a minimum of 10 times, with 6–8 seconds allotted for the completion of each stroke. The therapist’s dominant hand should lead. As the process continues, each stroke is coupled with the next, so that eventually all seven strokes are performed in succession, with the nondominant hand always following one stroke behind the dominant.
A cream should be applied prior to the initiation of the experience, using both hands simultaneously to do so. The cream application should bear no resemblance to the process; use a brief, gentle, and slow friction that allows the cream to be evenly distributed and warmed to skin temperature. Once applied, the hands should come to rest on the feet as therapist centering and focus ensues. The best position for this occurs with the palm covering the lateral malleolus, fingers 3–5 wrapped around the Achilles tendon, and the second finger pointing proximally with the thumb lying over the anterior ankle (resting position photo, page 54). This is an excellent period for the intentional flow of bioelectromagnetic energy to begin.
When ready, simply detach the nondominant hand and initiate the process. Follow the steps illustrated and detailed in annotated images presented throughout this article.
To conclude the process, there are several options. If using this technique to treat anxiety, it is customary to reverse the process by eliminating strokes until the therapist is performing only Stroke 1, ending with passive touch or energy-related work. It is not necessary to repeat every stroke 10 times. If using it as an introduction to leg work or for a general geriatric or hospice massage session, then once the seventh stroke is achieved, simply move forward into the next modality. Often, I find segueing into a period of stroking distally from the knee to the ankle along the peroneus longus is a satisfying conclusion. The resting position (page 54) is excellent to use prior to disconnecting from the client.
Here are a few more important suggestions to consider when using this technique:
1. Use a long-lasting, ultra-smooth cream for this process, preferably one that will endure approximately 20–30 minutes of use without need for reapplication. Lotion is absorbed too quickly. Oil is not recommended for dehydrated, frail, and/or elderly skin. It may be more dangerous, too, if the person is currently ambulatory and neglects to use slippers or stockings postintervention while walking on non-carpeted flooring. Also, oil is more difficult for caregivers to wash off of inflatable mattresses or sheets and it offers too much slide without enough grasp on the skin.
2. Gloves are not recommended. However, they may become necessary if your client has mycotic nails, numerous warts, or healing wounds. Be aware of allergies to latex and the susceptibility that gloves break down and tear after short periods of use with cream.
3. Hospital beds come in a variety of designs, most of which are ill suited to foot work. It is best to elevate the bed to a height that is comfortable rather than attempting to perform this process seated. If the bed is such that the foot board can be removed, do so, but be aware of the placement of mattress air pumps, charts, and other equipment that may be attached. If the board can’t be removed, then perhaps elevating the feet will bring them into a suitable position. Some air mattresses have their own foot piece, which is extremely challenging to overcome and work around; these typically require the process to be abandoned or greatly altered.
4. Attempt to make the surroundings as soothing as possible. Obtain permission from the roommate (if there is one) to lower or turn off the television, inform the staff not to interrupt for the duration of treatment, turn down the lights, draw the privacy curtains, and make your presence tranquil. Initiate aromatherapy if appropriate and allowed in your setting, and with permission from the client.
5. This is best performed with the client lying supine in bed. However, it has been successfully applied with clients seated in recliners, tilt-in-space wheelchairs, Geri chairs, Broda chairs, and while lying on a floor mattress or sofa. With these other options, please provide cushioning, preferably firm foam with a thick towel well secured under the client’s feet.
6. Music is quite helpful, for both you and the client. Of course, the selection will be influenced by personal taste and cultural/societal background, but essentially it should be slow, spatially oriented, and without an emphasized beat.
7. If staff members interrupt, do not cease the process and do not take your attention off of the client. Simply ignore them and continue, making eye contact if necessary to inform them that you and the client are in a deep communion. You can re-explain your manner once the process is complete and you have exited the room.
8. Therapeutic presence is mandatory for this process to be an effective intervention. If you are unaware of this crucial element of professional conduct, please use the email address below to request the unedited version of “Therapeutic Presence in Hospice Care” (a previously published article).
9. It is helpful to match the initial speed of the stroke with the client’s level of anxiety, slowing the process gradually as the client relaxes.
Once this process is mastered and applied with grace, a profound connection will arise between the therapist and the client. By engaging it, an exquisite communion develops, one grounded in sincere simplicity and attention to the moment. Clients will be soothed, anxiety transformed or resolved, and the room filled with the awareness of two souls who have shared intimacy. In the final analysis, it is less a powerful technique than it is a spiritual dance of mutual understanding.
John Mramor, MA, LMT, CMLDT, CR, NCTMB, is the massage therapist for the hospice division of the Visiting Nurse Association in Cleveland, Ohio. Mramor is certified in both manual lymph drainage and reflexology and is a member of various hospice organizations. He may be contacted at firstname.lastname@example.org