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GERIATRIC MASSAGE: The Evidence is in Your Hands

An Evidence-based Approach to Improve Functional Outcomes

and Quality of Life

Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS

Educise Resources Inc.

www.educise.comCopyright 2016 Educise Resources Inc. All Rights Reserved.

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Provider Disclaimer

• Allied Health Education and the presenter of this

webinar do not have any financial or other

associations with the manufacturers of any products

or suppliers of commercial services that may be

discussed or displayed in this presentation.

• There was no commercial support for this

presentation.

• The views expressed in this presentation are the

views and opinions of the presenter.

• Participants must use discretion when using the

information contained in this presentation.

THE GOLDEN YEARS!

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Instructor: Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS,CHy,DD

Physical therapist specializing in orthopedic rehab, muscle energy,

joint mobs, myofascial release, craniosacral & visceral

manipulation, precision exercise, medical massage, bioenergy,

functional training and evidence-based integrative medicine.

Owner of Flex Physical Therapy and Educise Resources Inc, Northport, NY.

www.educise.com4

A FEW AGING STATISTICS

• “People aged 65 and older presently make up 12 percent of the population, but they account for the following percentages in health care services:

• 26 percent of physician office visits

• 35 percent of hospital stays

• (From: http://medical-careers-review.toptenreviews.com/the-rising-health-care-needs-of-aging-baby-boomers.html)

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AGING STATS

• 34 percent of prescriptions

• 38 percent of emergency medical responses

• 90 percent of nursing home use”

• Life expectancy: In 2010, 40.2 million over 65

• By 2050, that figure is expected to double

• (From: http://medical-careers-review.toptenreviews.com/the-rising-health-care-needs-of-aging-baby-boomers.html)

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Complementary Medicine Use by Elderly

Researchers examined use of CAM by elderly (average 77.9 y/o)

• Chiropractic 61.9%

• Herbs 54.8%

• Massage 35.7%

• Acupuncture 33.3 %

(Williamson, et al, 2003)

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USE OF CAM IN AGING

Reasons for use of CAM:

• Used for pain: 54.8 percent

• For quality of life 45.2 percent

• For health 40.5 percent

(Williamson, 2003)

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MASSAGE CAN MAKE A DIFFERENCE

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WHAT IS MASSAGE THERAPY?

“Definition of Practice of Massage Therapy -Education Law, Section 7801

The practice of the profession of massage therapy is defined as engaging in applying a scientific system of activity to the muscular structure of the human body by means of stroking, kneading, tapping and vibrating with the hands or vibrators for the purpose of improving muscle tone and circulation.”

(From: http://www.op.nysed.gov/prof/mt/mtlic.htm)10

MASSAGE INTERVENTION STYLES

• Swedish/European

• Asian/ Acupressure/ Thai/ Amma/ Shiatsu

• Myofascial

• Neuromuscular

• Craniosacral

• Lymphatic

• Trigger point

• Many more

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MASSAGE INTERVENTION STYLES

• Trigger Point

• Deep Tissue

• Craniosacral

• Visceral

• Lymphatic drainage

• Other varieties

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SWEDISH/ CLASSIC MASSAGEIn classic or Swedish massage, 5 main strokes are

utilized:

• effleurage or long gliding or sliding, • petrissage or kneading,• Friction or rubbing,• tapotement or tapping, and • vibration or shaking.

• From:http://en.wikipedia.org/wiki/Massage#Swedish_massage

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Swedish Massage Improved Autonomic Function in Elder Women with pre-HTN

Caromano et al studied effect on one 60 min. massage on blood pressure on 58 pre-hypertensive sedentary older women

Post-massage, • 13% reduction in systolic BP and • 9.4% lower diastolic BP

(Caromano, et al, International Archives of Medicine, 2015)14

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ASIAN/ ACUPRESSURE MASSAGE• “Two types of traditional Chinese massage exist -

Tui na (推拿) which focuses on pushing, stretching and kneading the muscle and Zhi Ya (指壓) which focuses on pinching and pressing at acupressurepoints. Both are based on principles from Traditional Chinese Medicine. Though in the Western countries Tui Na is viewed as massage, it is not. Massage of Chinese Medicine is known as Anmo (按摩), which is the foundation of Japan's Anma.”

• From: http://en.wikipedia.org/wiki/Massage#Swedish_massage16

ASIAN MASSAGE- TuiNa

• “Within the foundation of Tui Na, Traditional Chinese Medicine principles are followed, from

Meridian Applications to Herbal Formulas,

Qigong Therapy and heated herbal application (Moxa).

Technique applications such as friction and vibration are used as well.”

(From: http://en.wikipedia.org/wiki/Massage#Swedish_massage)17

SHIATSU AND AMMA MASSAGE• “Shiatsu (指圧) (shi meaning finger and atsu

meaning pressure) is a Japanese therapy that uses pressure applied with thumbs, fingers and palms to the same energy meridians as acupressure and incorporates stretching.”

(From: http://en.wikipedia.org/wiki/Massage#Swedish_massage)

• Amma massage is a version of Acupressure with specific application of pressure, holding and soft tissue manipulation to improve energy flow through the acupuncture channels or points for optimal health.

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Effect on Balance in Type 2 Diabetic Peripheral Neuropathy

Chatchawan et al RCT of 60 pts., 40-70 y/o:

30 control (exercise, education), vs. 30 Thai foot massage 3x/wk x 2 wks for 30 mins.

Results: Timed Up and Go, One Leg Stance, ROM foot and foot sensation

Significant improvement in massage group for ROM, TUG, and foot sensation (Semmes Weinstein

monofilament test) (Chatchawan, et al, Med Sci Monit Basic Res. 2015)

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Effect of Acupressure for Incontinence

Chang’s RCT of women with urodynamic stress incontinence:

N=81 women 18-60, received either acupressure, sham or control 3x/wk x 30 mins. For 30 visits.

Significant difference in the acupressure group. :

• pelvic floor muscle strength

• urine leakage severity, and

• Kings Health questionnaire(Chang, 2011)

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Acupressure Evidence- Sleep

• Shariati et al did RCT of 48 end-stage hemodialysis pts. with poor sleep, gave acupressure using He7, Li4, & Sp6 points x 4 wks.

• Results: Statistically significant improvement in treatment group for: Pittsburgh Sleep Quality Index, sleep quality, latency, duration, efficiency and disturbance, use of sleep meds and daytime disturbance.

(Shariati, et al, 2012)

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Chinese Massage Improves Gait, Pain and Function

Study of 20 women with knee osteoarthritis given massage 3x/wk x 2 wks.

Results: Improved pain relief, stiffness and physical function based on gait analysis (6 camera infrared and WOMAC scores)(p<0.05)

Improved gait speed, step width and total support time after massage

(Qingguang et al, Jnl Traditional Chinese Medicine, 2015)22

Effect of Anma Massage on Shoulder Mobility in Parkinson’s Patients

Suoh, et al showed improvement in nursing home residents with Parkinson’s (PD) on the Hoehnand Yahr scale and shoulder range of motion

Studied 10 PD pts. Compared intervention to nonintervention periods

After 30-40 mins treatment 1x/wk x 7 wks

Immediate and significant increase in shoulder ROM, including 1 wk. later

(Suoh et al, Jnl Bodywk Movement Ther. 2015)

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MYOFASCIAL RELEASE MASSAGE

Myofascial Release

• is a method of applying specific pressure and stretches to the fascial elements

• for the purpose of improving mobility and function by breaking abnormal crosslinks and scarring in the fasciae.

• AKA: fascial mobilization, soft tissue mobilization, Rolfing, deep tissue work, fascialrelease, deep connective tissue massage

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MFR TECHNIQUESStrokes may include:

• skin rolling, skin gliding, shearing

• J-stroking

• Muscle play, stretching across the fibers

• Direct pressure: tissue compression with 3-D tension application

• distraction/ traction pulling

• Frictions: circular or z-friction

• Unwinding/ Somatoemotional release25

Many Types of Myofascial Techniques

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GOALS of MFR

• To apply strain/stretch to stiff tissues

• To lengthen and release scars or adhesions

• To reduce pain

• To improve circulation

• To improve flexibility, range of motion

• To improve or restore functional mobility.

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MFR STYLES

• Direct technique: engages the barriers or restrictions to motion to apply a strain, lengthening

• Indirect technique: moves the tissue into the direction of ease, where the tissue moves freely, shortening

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MFR RESEARCH

There is an abundance of current research on fascia and the efficacy of myofascialrelease at:

www.fasciacongress.org

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NEUROMUSCULAR MASSAGE

• “(NMT) is a form of soft tissue manual therapy. It is distinguished from other types of massage in that a quasi-static pressure is applied to the skin with the aim of stimulating specific areas of skeletal muscle. Often these areas of muscle are myofascial trigger points.”

• (From: http://en.wikipedia.org/wiki/Neuromuscular_therapy)

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NMT Massage

• NMT is a comprehensive program of soft tissue manipulation techniques that balance the central nervous system (brain, spinal column and nerves) with the structure and form of the musculoskeletal system. NMT is based on neurological laws that explain how the central nervous system maintains homeostatic balance.”

• (From: http://en.wikipedia.org/wiki/Neuromuscular_therapy)

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TRIGGER POINT THERAPY• “involves deactivating trigger points that may

cause local pain or refer pain and other sensations, such as headaches, in other parts of the body. Manual pressure, vibration, injection, or other treatment is applied to these points to relieve myofascial pain. “

• Trigger points were first discovered and mapped by Janet G. Travell (president Kennedy's physician) and David Simons.” (From:

http://en.wikipedia.org/wiki/Massage#Swedish_massage

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TRIGGER POINTS (TPs)

“Trigger points were first discovered and mapped by Janet G. Travell (President Kennedy's physician) and David Simons.”

• Trigger points are often called myofascialtrigger points (MfTP) or even just tender points, but there is a distinction, as defined by Travell and Simons

• From: http://en.wikipedia.org/wiki/Massage#Swedish_massage

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TRIGGER POINT

“A myofascial trigger point is a hyperirritable locus within a taut band of skeletal muscle, located in the muscular tissue and/or its associated fascia” (Travell, p. 12)

TPs are :

• painful on compression

• refer pain to a specific region

• cause jumping or twitching when palpated.

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ISCHEMIC COMPRESSION• Ischemic compression of the TP aims to reduce

pain perception (by increasing circulation or gating pain) and to reduce muscle tension.

• Practitioner places a finger or blunt tool directly on the trigger point and holds pressure there for several seconds up to 2 minutes, which may be uncomfortable to the patient

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HOW IT WORKS

• Gate Control Theory: Melzack and Wall:

• pain perception is reduced by competition of messages traveling up the spinal cord to the thalamus “gate”,

• where stimulation of large nerve fibers (A fibers) supercedes the pain messages carried by small nerve (C) fibers, “closing the gate” to pain transmission

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Ischemic Compression

• Another theory of the mechanism of IC is based on circulation

• As the practitioner holds pressure on the TP, the blood is forced out of the region, causing relative ischemia temporarily.

• As the pressure is released, fresh blood flows into the region, bringing in oxygen and increasing circulation, to help relieve pain

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DEEP TISSUE MASSAGE

• “category of massage therapy, used to treat particular muscular-skeletal disorders and complaints and employs a dedicated set of techniques and strokes to achieve a measure of relief. It should not be confused with “deep pressure” massage, which is one that is performed with sustained strong, occasionally intense pressure throughout an entire full-body session, and that is not performed to address a specific complaint. “

• (From: http://en.wikipedia.org/wiki/Massage#Swedish_massage) 38

DEEP TISSUE

“Deep tissue massage is applied to both the superficial and deep layers of muscles, fascia, and other structures. The sessions are often quite intense as a result of the deliberate, focused work.”

(From: http://en.wikipedia.org/wiki/Massage#Swedish_massage)

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CRANIOSACRAL THERAPY

CST is a gentle intervention using light pressure on the skeletal or myofascial structures to balance the craniosacral system. Sutherland and Upledger described an intrinsic rhythm, craniosacral rhythm, (CSR) as the result of the flow of cerebrospinal fluid through the brain and spinal cord.

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CRANIOSACRAL RHYTHM

CSR is the rhythmic pulsation palpated over the bones of the cranium and body, as the result of the production and absorption of cerebrospinal fluid through the cranial dural membranes.

CSR is palpated as a widening (flexion) and narrowing (extension) of the cranial bones or rotation of the paired bones of the body, as fluid is produced or absorbed.

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Craniosacral Rhythm: CSR• Palpate and facilitate normalizing CSR for:

• rate, (normal 6-12x/min)

• amplitude,

• rhythm,

• quality and

• symmetry,

• to identify and treat restrictions in the cranial/dural membranes and fasciae, using light pressure and movement to facilitate release of tension and promote normal mobility.

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CST

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Craniosacral Therapy Still Point Effect on Agitation in Dementia

Gerdner, et al: mixed study of 9 elderly with dementia. Intervention: CST still point daily x 6wks

Measured: modified Cohen-Mansfield Agitation Inventory (M-CMAI) at baseline (3 weeks), intervention (6 weeks), and followup after 3 wks

Results: statistically significant • Decrease in total M-CMAI during the 6 wk CST• Improved subscales for verbal agitation and physical

nonaggression scores• Caregivers reported better cooperation with ADLs

and more meaningful interactions with CST(Gerdner, et al, 2008)

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VISCERAL MASSAGE, MANIPULATION

• Visceral manipulation uses light, precise application of gentle and deep pressures and stretch applied to the visceral organs and their fasciae to release adhesions (cicatrix, scars) and promote normal organ mobility, motility, and function for health.

• Jean-Pierre Barral, DO,PT created a specific approach to identifying and treating visceral dysfunction

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Visceral Massage/ ManipulationEvaluates mobility/motility of the

organs, uses gentle pressure to induce relaxation and mobilization

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MANUAL LYMPHATIC DRAINAGE

• MLD: “the application of light rhythmic strokes, similar to those used in effleurage, to the skin and superficial fascia in the direction of the heart to increase the drainage of lymph from the involved structures”

(From: http://medical-dictionary.thefreedictionary.com/manual+lymph+drainage)

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MLD Evidence

• Vairo et al in a systematic review could not provide adequate evidence for using MLD: “efficacy of MLDT in sports medicine and rehabilitation is specific to resolution of enzyme serum levels associated with acute skeletal muscle cell damage as well as reduction of edema following acute ankle joint sprain and radial wrist fracture.”

• (Vairo, et al, 2009)

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MANY ALTERNATIVE MASSAGE VARIETIES TO CHOOSE FROM

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HOW CAN MASSAGE HELP WITH THE CHANGES INVOLVED IN THE

AGING PROCESS?

Physiological Effects of Aging

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Presby= old age: Changes with Age

• Ears: Presbycusis-

hearing deficiency for high pitch sound

• Eyes: Presbyopia:

loss of vision: patients have difficulty seeing edge of the chair, curb or step; suggest using bright color contrasts to highlight edges

(Lewis, pp. 124-125)

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Physiological Effects of Aging

Reduction in:

• basal metabolic rate BMR

• endurance (aerobic capacity VO2max)

• insulin sensitivity

• body water

• skeletal muscle mass (sarcopenia)

(Guccione, p. 29)

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Physiological Effects of AgingIncrease in:

• Fat mass

• LDL cholesterol

• Hypertension

• Atherosclerosis

• Diabetes (Type 2)

• Accumulative cell and tissue damage (traumas, injuries, smoking, environmental, diet, etc)

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Physiological Changes with Aging

• Fascial collagen cross-links increase stiffness

• Glycation of collagen (damaged protein: stiffness of skin, tendons, blood vessels, organs)

• Damage from free radicals- oxidation

• Shortening of replicating telomeres over time

• Reduced cardiac functional reserve capacity

• Loss of vascular elasticity

(Guccione, p. 31-2)55

Functional Effects of Aging

Reduced physical activity:Does it contribute to deficits associated with aging

or is it the result of aging changes or both?

“reduction in muscle strength is a major cause of disability in the older adult since strength and power are major components of gait, balance, and the ability to walk.” (Guccione, p. 45)

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Musculoskeletal Changes with Aging

Decreases in:

• Muscle mass and fiber size, (type 2 fast twitch)

• Motor units, motor neurons and axons

• Contraction velocity and force

• Muscle mitochondria

• Blood flow, capillary density• (Guccione, p.48)

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Musculoskeletal Factors in Aging

All contribute to decreased physical activity in the older adult

• Joint and muscle stiffness

• Limited range of motion

• Inflamed joints- arthritis- pain

• Osteopenia, osteoporosis-

fractures

• Poor posture- forward head, kyphosis, flexed trunk, hips, knees

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BALANCE ISSUES: SNF Residents

“Muscle weakness and walking or gait problems are the most common causes of falls among nursing home residents. These problems account for about 24% of the falls in nursing homes.”

(From:http://www.cdc.gov/HomeandRecreationalSafety/Falls/nursing.html. Accessed 2/25/13)

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Vestibular Changes in Aging

• Presbyastasis: dysequilibrium related to age

• Vestibular system studies found a reduction in utricle and saccule hair cells of 20% and semicircular canal hair cells of 40%

• Vestibular nuclear neurons are reduced by 3% each decade

(Guccione, P. 90)

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Balance Declines with Age

• Bohannon et al investigated the relationship between age and balance test performance in 184 adults 20 to 79 yrs.

• They measured double and single leg balance times with eyes open or closed.

• Results: unilateral balance decreases with age.

(Bohannon, RW, Larkin, PA, et al., pp.1067- 1070)

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Neurological Factors in Aging-reflex sensitivity is reduced-reduced proprioception

- slower reaction time-increased postural sway-decreased sensation - decreased coordination

Peripheral neuropathy: loss of sensation,inability to feel changes in surfaces

and joint motions, proprioceptive loss (Lewis, p. 107)

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Neurological ProblemsNeuromuscular or Neurological disease:

• CNS injury or disease, stroke, brain tumor

• Multiple sclerosis

• Parkinsons disease or symptoms

May have rigidity, spasticity or flaccidity of muscles, develop contractures

Coordination problems

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Cardiovascular Factors in Aging

Reduced circulation: get medical clearance first!

- orthostatic hypotension (dizziness)

– vertebral artery compromise

– History of MI/ heart failure/ heart surgery leading to reduced endurance for ADLs and exercise

– Peripheral circulatory disease

– Capillary membrane diffusion reduction

(Lewis, p. 107)

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Cardiovascular Factors

• Hypoxemia or anemia

• Low blood volume

• Electrolyte imbalances

• Hyper- or hypotensive issues

• Cardiac or blood pressure meds

• Varicose veins- blood clot caution: medical clearance, doppler testing for circulation

• Spider veins

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Medical Factors

• Incontinence is common, be sure protective appliances/diapers in place

Be sure patient uses toilet prior to massage

• Heartburn, Gastroesophageal reflux (GERD): Patients may regurgitate food in supine or

prone, keep in semi-reclining or upright position

• Very frail patients: limit time to 15-20 mins. with warmup/cooldown

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Medical Factors

• Orthostatic hypotension may cause dizziness upon moving from recumbent or sitting to standing or upright posture

• Ask patient to move slowly, take deep breaths, wait to adjust to the new posture.

• Allow time to adjust and guard the patient.

• Risk of falls and injury

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Psychological Factors in AgingThings ain’t what they used to be!

• Poor memory

• Cognitive impairment or dementia

• Confusion

• Fear of falling

• Reduced self-efficacy

• Loss of independence

• Depression

• Social isolation- they love your company

(Lewis, p. 108)

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Drug Use in the Elderly• Drug metabolism and distribution decrease with

age, liver and kidneys are less efficient • Drugs may stay in their system longer• No one knows the interactions of multiple drugs in

the body, most studies are of one or few drug combinations

• Ask for list of patient’s Rx from the pharmacist

Note blood thinners/anticoagulants, statins, cardiac and cognitive impairing drugs, check on side effects

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SKIN CHANGES WITH AGING

• Skin fragility or loss of integrity

• Vascular insufficiency/ neuropathy/ plantar ulcers

More common in diabetes/ neuropathy

• Chronic dermal wounds develop

• Pressure ulcers or neuropathic ulcers (feet)

• Affected by lifestyle: smoking, sedentary behavior, diet of high fat intake

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INTEGUMENTARY CONCERNS• Thinning skin: reduced collagen and hydration

• Anticoagulant therapy- bleeds/bruises readily

• Slow wound healing

• Must avoid areas of wound healing and bruises during massage

• Must use lighter pressure to avoid bruising fragile tissues

• Must avoid strong pulling or stretching the skin which may disrupt skin integrity

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INTEGUMENTARY CONCERNS

• Depending on the skin issue, practitioners may use gloves during massage to avoid infection, elderly patients may have weak immune systems

• Patients may have allergies or sensitivity to the massage creams or oils, test a small area first

• Sometimes hypoallergenic ultrasound gel may be used for massage but it dries up quickly

• Inquire what lotion they use or ask: Nursing or family may provide a lotion they tolerate well

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Aging Varies

• Everyone ages differently

• People have various resources and support systems to assist them when they are impaired

• Over time, people lose their adaptive capacity to compensate for acquired physiological deficits. (Guccione, p. 281)

• Accumulation of injuries over the years

• Lifestyle and habits

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Whether your patient is a fragile, 104 year old lady in the SNF or

an 86 year old active golfer at homeThey may benefit from therapeutic massage to:

• Improve mobility and functional ability

• Reduce pain

• Improve circulation

• Reduce muscle tension and trigger points

• Promote relaxation and sleep

• Decrease heart rate and blood pressure

• Reduce anxiety and agitation74

THERAPEUTIC MASSAGEInfluences some of the problems associated with aging:

• Circulation improves

• Muscles relax

• Soft tissue/ fascial stretching for improved ROM

• Stimulates flow of lymph and venous return

• Pain relief

• Relief of constipation

• Improved sleep

• Decreased anxiety

• Better quality of life75

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How is Massage Modified to Address Special Conditions in the Elderly

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MASSAGE ADAPTATIONS FOR ELDERLY

Technique-

• Begin with a few minutes light effleurage for warmup strokes, keep the pressure very light in direction of circulation

• Apply pressure gradually in increments to allow adaptation to your touch and modification of pressure according to the tissue tolerance and fragility, obtain feedback

• Use lymphatic drainage strokes toward the heart

• Gradually include gentle petrissage strokes to move and stretch the muscles

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MASSAGE ADAPTATIONS FOR ELDERLY

• Check skin integrity and bone density (DEXA) to determine level of fragility

• Avoid deep trigger point compression: bruising

• Keep pressure lighter for fragile patients, no elbowing or knuckling over bony surfaces

• Caution working over osteoporotic ribs, spine, and hips

• Soft slow forearm strokes are relaxing

• Sense to move deeper only as muscles soften and relax, non-force

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MASSAGE ADAPTATIONS FOR ELDERLYWhen applying massage, use full contact of your

hand(s); avoid applying direct pressure with fingertips which may cause pain or bruising of frail skin,

Pay attention to muscle fiber orientation to stroke longitudinally with the fibers, with circulation

Stroking transversely may be fine for less frail persons but may cause irritation to muscle with thin skin and hyperactive trigger points (snapping palpation/twitches)

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MASSAGE TECHNIQUE

• Circular and longitudinal strokes (effleurage) and kneading (petrissage) are readily applied using lubricants or through clothing if patients cannot change

• Muscle play may be used directly on skin or through clothing, lifting the muscle belly gently and stretching it transversely to its fibers

• Gentle range of motion/ stretching is a great followup to massage

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MASSAGE ADAPTATIONS FOR ELDERLY

Positioning- Use plenty of pillows, bolsters, towel or sheet rolls to fully support the part you are massaging for maximal comfort/ relaxation and to promote good circulation

• Be aware of GERD, effect of position on dizziness, indigestion, or painful/inflamed joints

• Many prefer sidelying or positioned semi-recumbent on a big wedge pillow or elevate head of bed

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ADAPTATIONS FOR ELDERLY

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•Elevate dependent areas with poor circulation

•Draping- massage clothed or draped under sheet

•Provide blankets for warmthas needed

•If massaging on skin, use lubricant

MASSAGE ADAPTATIONS FOR ELDERLY

• Equipment- hospital bed, plinth, wheelchair

• Privacy- ensure quiet uninterrupted time

• Noise and lighting- low lights are relaxing

• Temperature- elders become cold, keep socks on, drape for warmth adequately

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MASSAGE ADAPTATIONS FOR ELDERLY• Skin hygiene- wipe patient’s feet/hands after to avoid

slipping when transferring after massage• Gloves or no gloves (avoid latex- allergies) • Alert patient and caregivers of any unusual skin

discoloration, rash, skin lesions to have examined• Skin tags and pigmented moles are common;

however have them examined by MD for changes, can massage them

• Do not rub lipomas, usually benign fatty cysts palpated subcutaneously, feel like slippery beans under the skin, common at iliac crest, refer for examination

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MASSAGE ADAPTATIONS FOR ELDERLY

• Inspect patient’s skin, especially the feet, carefully for areas of excessive pressure, blisters, redness, irritation, nail problems, these may become infected or are a sign of circulatory or neuropathic issues, or improper footwear

• Alert caregivers/ nursing/medical staff of any changes or problems which may need medical intervention

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Special Considerations• Products: Liberal use of lubricant, to avoid skin

drag

• Check on sensitivity to products containing nuts, parabens, fragrances, preservatives

• Allergies

• Aromatherapy is great if they are not sensitive to it

• Oil / Lotion /Gel /Powder /Silicone

• Typical hospital grade skin care products

• Conversation with patients86

Communicating with Elders

Patient communication:

• Often elderly have low vision and poor hearing, do not shout at them

• Look directly at them when speaking, stay close enough to allow them to hear and see your expression and gestures

• Touching their hand or arm implies connection and receptivity, and is reassuring to some

• Be patient, they may be forgetful, repeat things87

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Scheduling Therapeutic Massage

- Allow digestion for at least 1 hr. after meals

– Allow extra time for positioning, draping, setup

– Educate them about communicating their response to massage, if painful or too deep/too light, their needs and preferences, what areas feel tight, cold or painful

– Uninterrupted treatments are more relaxing

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SCHEDULING

– Patients are asked to empty bladder/bowel first

– Use massage after bathing to moisturize the skin

– Pre-exercise will help with warm-up for stretching

– Massage later in the day may help them to sleep

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DOSAGE OF MASSAGE

It is difficult to do massage research dosing since each patient has unique needs and limitations

Some studies attempted to standardize treatment

• Dosage- frequency, duration-

• studies generally use from 15-60 mins. of Swedish

• Standard or individualized procedure

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Manualized Protocol of Massage

Ali et al studied massage clinical trial design to make a semi-structured standardized protocol for patients with knee OA over 24 wks, N=125

Interventions: Used 30 min/wk or 60 min/wk or every 2 wks vs. usual care

Typical Swedish massage strokes only:

(petrissage, effleurage, tapotement, skin rolling, vibration, friction)

(Ali, et al, 2012)

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Continued Manualized Protocol

Result: the 60 min. massage group had significant improvement in:

• WOMAC scores for pain, function vs. usual care• increased effect with incr. time (vs. 30 min massage)

Recommend:• Use standardized protocol of Swedish massage for • 60 mins. once/wk for research purposes to improve

outcomes for osteoarthritis• WOMAC arthritis index has 24 questions on pain,

function and stiffness(Ali, et al, 2012)

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TREATMENT LOCATIONS

• Inpatient

• Outpatient

• Nursing home or SNF

• Assisted living facility

• Home health

• Hospice

• Insurance issues: CPT code 97124 for Massage

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CONTRAINDICATIONS & PRECAUTIONS

Any condition for which motion, pressure, or touch to a region is detrimental, includes not limited to:

• Unhealed fracture or dislocation

• Open or sutured wounds

• Infections, cellulitis, fevers: NO massage

• Acute inflammations- avoid area

• Blood clots, thrombosis, emboli, thrombophlebitis- get medical care

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CONTRAINDICATIONS & PRECAUTIONS• Hypersensitivity/ intolerance to touch (Reflex

sympathetic dystrophy, complex regional pain, acute active trigger points or severe tenderness

(avoid area, work around it, do not cause more pain)

• Cardiac insufficiency- massage increases circulation, heart failure cannot compensate

(measure vital signs HR, BP, RR- for stability)

• Severe edema (need medical management, lymph drainage)

• Aneurysm95

CONTRAINDICATIONS & PRECAUTIONS

• Loss of skin integrity: dryness, fragility, dermatitis, burns, rashes, sores, cuts, blisters, hives, keloids, excess peeling, bruises, avoid the area

• Patients with decreased sensation, neuropathy- be gentle, they cannot feel if they are bruising

• Patients with questionable cooperation or inappropriate behavior

• Osteoporosis, osteopenia, fragile bones: avoid strong pressure, tapotement or strong vibration techniques

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CONTRAINDICATIONS & PRECAUTIONS

• Radiation dermatitis (avoid area: is a burn post radiation)

• Anticoagulant drugs (coumadin, heparin, warfarin, aspirin, NSAIDS may cause hemorrhage locally or bruising, use light pressure)

• Medical implants: avoid catheters, pacemakers

• Massage lightly around metal implants such as joint replacements or orthopedic internal fixation devices, esp. subcutaneous screws

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MEDICAL CLEARANCE If you don’t know you don’t go!

Before providing therapeutic massage for an elderly person, you should obtain medical

clearance and have a thorough medical examination of the patient.

You must be aware of the patient’s medical conditions to promote health and avoid injury.

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PRIMARY IMPAIRMENTS in ELDERLY• Stiffness and limited mobility• Poor circulation• Trigger points• Muscle spasm or contracture• Joint and muscle pain• Edema• Inability to sleep well• Constipation• Loss of balance• Incontinence• Dry, fragile skin

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RESEARCH ON MEDICAL MASSAGE FOR THE ELDERLY

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Effect of Massage and Meditation at End of Life

Downey et al reviewed RCT of terminally ill patients

Outcomes: quality of life and pain level

N= 167 patients in 2 groups:

1. 35 mins spinal massage 2x/wk vs.

2. active controls (received a hospice visitor but no massage)

Patients preferences predict outcomes

Result: significant improvements in QOL and pain from massage (Downey, ET AL, 2009)

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Effect of Massage on Tension, Anxiety and Pain

Wentworth et al pilot study on n=131

patients awaiting invasive CV procedure

Random pre/post test design: massage vs. control

Intervention: 20 min massage 30 min pre-procedure

Result: VAS scales for pain, tension, anxiety and satisfaction indicated massage could be used pre-procedure to alleviate tension, anxiety, pain

(Wentworth, ET AL, 2009)

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Effect of Massage after SurgeryBauer, et al RCT of patients after CV surgery, n=113

patients, massage group or control (relaxation)

Result: Significantly reduction in massage group

• Scores for pain, tension and anxiety,

• High patient satisfaction

• Recommend massage post invasive cardiovascular surgery

(Bauer, et al, 2010)

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Effect on Sleep with DementiaHarris, et al pilot study of n=40 nursing home

residents 65+y/o with sleep disturbances and dementia

2 groups: 1. slow stroke 3 min. back massage or 2. usual care

Measured actigraphy sleep data at baseline and post intervention

Massage group had increase of 36 mins. sleep vscontrols, but not significant; need more study to determine dosing to improve sleep

(Harris, et al, 2012)

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Effect of Foot Massage on Agitation in LTC Patients with Dementia

Burne et al studied n=17 persons with dementia/ agitation in LTC (avg. 84.7 y/o)Intervention: 10 min. foot massage 1x/day x 14 daysMeasured: Revised Memory and Behavior Problems

Checklist (RMBPC) and Cohen-Mansfield Agitation Inventory (CMAI) baseline, post-tx and post 2 wks.

Result: Both scores significantly reduced at post-tx and at 2 week followup:

• massage helps reduce agitation and • improves behavior in dementia patients(Burne Johnson, et al, 2011)

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Effect on Agitation in Nursing Home Residents with Cognitive Impairment

Holliday-Welsh et al reported significant improvements in agitation in patients who received massage both during and after intervention:

Result:4 behaviors improved:

• physically agitated/abusive

• verbally agitated/abusive

• wandering and

• resists care. (Holliday-Welsh, et al, 2011) 107

EFFECT ON SEVERE DEMENTIA

Suzuki et al studied effect of 30 sessions of tactile massage for 6 wks on patients with severe dementia vs. controls. Results: massage group

• Improvement in Behavioral and psychological symptoms: significantly lower aggressiveness

• Decreased Chromogranin A, a stress measure

• Non-treated patients had declines in intellectual and emotional function

(Suzuki, et al, 2010)108

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Health Outcomes in Older Adults

Munk and Zanjani reported significantly improved health scores in N=144 subjects aged 60+ y/o who had massage in the previous year, compared to those who did not receive massage.

Measured self-reported health outcome scores:

physical-related limitations, emotional well-being, emotional-related limitations

(controlled for comorbidities and age)(Munk and Zanjani, 2011)

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Effect of Massage on ParkinsonsHernandez-Reif et al studied people with Parkinsons,

N=16 subjects, mean age:58

Intervention: 2x/wk x 5 wks of 30-min massage therapy or progressive muscle relaxation

Outcomes: epinephrine/norepinephrine and both physician and self-reported improvement in daily functioning

Results: Massage group:

• lower norepinephrine and epinephrine levels

• improved self and doctor- reported ADL outcomes (Hernandez-Reif, 2002)

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Effect on Bone Cancer Pain

Jane et al did quasi-experimental study on N=30 patients with metastatic bone pain

Measured: Heart rate, mean arterial pressure, Pain, anxiety, (VAS), and McGill Pain Questionnaire (MSF-MPQ) pre and post massage

Results: immediate, short (30 min), and long outcomes (16-18hrs) of

• Reduced anxiety and pain

• No adverse effects

• RCTs are recommended(Jane, et al, 2009) 111

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Effect on Stress Perception and Cortisol with Breast Cancer

Listing, et al, RCT of 24 women with breast cancer,

Intervention: 2 groups: classical massage 2x/wk for 30 mins or control of routine care

Measured: 1. Perceived Stress Questionnaire PSQ 2. Berlin Mood Questionnaire BMQ

3. Blood cortisol and serotonin

At baseline, and at end of 2 and 6 wks post

Results: Cortisol and PSQ significantly reduced after massage (From: https://line.spriger.com/article/10.1007%2Fs00737-009-

0143-9?LI=true)

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Effect on Immune and NeuroendocrineFunctions in Breast Cancer

Hernandez-Reif, et al RCT of N=34 females with stage 1 or 2 breast cancer post-surgery

Intervention: massage to arms, head, back, legs, feet for 30 mins 3x/wk x 5 wks (stretching, stroking, squeezing) or control

Results: day 1 and last day:

• Reduced anger, anxiety and depressed mood;

• Long term: functioning, hostility, coping style, urinary catecholamines, dopamine, lymphocytes, natural killer cell # and serotonin (Hernandez-Reif, et al, 2004)

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Effect on Patients with Advanced IllnessMitchinson et al studied N=153 VA patients

Measured: anxiety, dyspnea, pain, inner peace and relaxation,

Intervention: pre and post massage

Results: Statistically significant short-term changes in anxiety, pain, relaxation, inner peace

• Massage can benefit palliative care patients

by reducing pain and symptoms.(Mitchenson et al, 2013)

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Effect on Constipation

Lai et al studies effect of aromatherapy massage

on constipation in patients with advanced cancer

Measured pre and post test bowel movement frequency, constipation scale and constipation severity level

Interventions: regular massage, aroma massage and control

Result: significant improvement in aroma massage group for constipation assessment scale, bowel frequency, quality of life (Lai, et al, 2010)

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Effect on Stroke Self-Efficacy

Wattakiecharoen reported a RCT: of N=60 home care patients post-stroke

1. Thai massage group with routine care and 2. control group of routine care, at baseline and after 12 wks

Measured: physical functional status, (Barthel Index and Chula ADL), perceived self-efficacy, outcome expectation

Result: Significant increase in mean score on perceived self-efficacy for exercise and outcome expectation in massage group (Wattakiecharoen, 2008)

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DIABETES

Systematic Review by Ezzo et al reported:

• “Massage at injection sites may increase insulin absorption.

• In addition, uncontrolled studies suggest that massage may have a positive effect on blood glucose levels and symptoms of diabetic neuropathy.

• However, randomized, placebo-controlled studies are needed to confirm any short- and long-term benefits of massage as a complementary treatment for diabetes and to further define an optimal massage treatment.” (Ezzo, et al, 2001)

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DIABETES CONSIDERATIONS

Caution must be used with diabetics:

• Skin fragility

• Circulation deficits

• Neuropathy

Modifications: massage using

• light pressure, avoid bruising

• gentle, slow motions

• generous lubricants, avoid skin drag and tearing

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USE OF SEDATIVES

Nelson’s randomized pilot study

Showed massage used at bedtime reduced the

request for sedative/hypnotic drugs by

13% in the elderly.

(Nelson, et al, 2010)

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EFFECT ON BALANCE, CARDOIVASCULAR AND NERVOUS SYSTEM

Sefton et al measured effects of 60 mins. of full-body therapeutic massage given to 35 healthy older adults (avg. age 62.9yrs) for 6 wks. vs. control group given quiet relaxation

Results: immediate post-treatment

• Immediate elevation of DBP

• No increase in instability

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SEFTON continued

Results after 6 weeks:

for massage group:

• Lower systolic blood pressure

• Increased balance (displacement area, velocity) in the 60 mins post massage

• Some difference in EMG reflexes Hmax/Mmax,

showing lower motoneuron excitability

(Sefton, et al, 2012)121

Effect on BalanceValliant et al used RCT of N=28 nursing home

residents (mean age 78.8y/o)

Measured: Lateral Reach test, One Leg Balance, Timed Up and go, (TUG) pre and post intervention

Intervention: Massage and joint mobilization of feet and ankles vs. placebo control: 1 session

Results: Significant improvement in massage-mob group for One Leg Balance and TUG (Valliant, et al, 2009)

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EFFECT ON CHRONIC BACK PAINSritoomma et al’s RCT studied effects of Swedish

or Thai massage on older adults with back pain

N=140 patients received wither Swedish or traditional Thai massage: 30 minas. 2x/wk x 5 wks.

Measured Pain scale (VAS) post tx,

Oswestry Back Disability Index (ODI) and short form McGill Pain Questionnaire (MPQ) measured at 6 and 15 wks post,

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Chronic pain continued

Results: Immediate, 6 and 12 weeks post session:

• Significant improvement in in disability (ODI) and pain (VAS, [short term] and MPQ [long-term] scores) across time

• Greater improvement in the Swedish massage group, compared to Thai for all variables

(Sritoomma, et al, 2103)

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Did Massage Make a Difference? Functional Outcome Measures

• Importance of objective functional outcome measures for the elderly

• Question of efficacy for a given intervention

• Can one prove the intervention made a difference?

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Unilateral Stance Test / Single Leg ST

• Test: Ask patient to cross arms and lift favored leg

• Shoes on, average of 3 trials, keep eyes open

• Result: High risk of falls/injury if below 5 seconds

• Normative Values for single leg stance time

• Age 40-49 29.7 secs.

• Age 50-59 29.4 secs.

• Age 60-69 22.5 secs.

• Age 70-79 14.2 secs.

• (Disqualify if elevated foot hits ground, arms uncross, stance leg moves, or trunk tilts >45 degrees)

• (Lewis, p. 113)

Functional Reach Test: FRT

• Patient standing, reaches forward as far as possible with hands along a tape measure on the wall

• Measure excursion of reach without falling

• “Duncan and colleagues have shown that frail persons with reaches less than 6 inches have 4 times the likelihood of falling than persons with a reach greater that 10 inches”. (Guccione, p. 288)

MEANS FOR FUNCTIONAL REACH TEST (from Isles, et al, p. 1370, 2004)

AGE 20-29 30-39 40-49 50-59 60-69 70-79

Isles Mean in cm.

42.71 41.01 40.37 38.08 36.85 34.13

OthersDuncanBrauer

37.08 35.05 35.05 35.0529.6

26.6729.6

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Sitting FRT Means (Thompson and Medley, 2007)

AGEYrs.

21-39 40-59 65-93

Lateral reach in sitting, cm.

44.9 42.3 32.9

Forward reach in sitting, cm.

29.5 26.7 20.3

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Falls Efficacy Scale (FES)

• Questionnaire: “On a scale from 1 to 10,

• with 1 being very confident and

• 10 not being confident at all, how confident are you that you do the following activities without falling?...

• A score of greater than 70 indicates that the person has a fear of falling”

(Falls Efficacy Scale, in Lewis, p. 236.)

Falls Efficacy Scale Activities Score 1-10

• “Take a bath or shower

• Reach in to cabinets or closets

• Walk around the house

• Prepare meals not requiring carrying heavy or hot objects

• Get in or out of bed

• Answer the door or telephone

• Get in or out of a chair

• Getting dressed and undressed

• Personal grooming (i.e. washing your face)

• Getting on and off the toilet

• Score 1 very confident 10 not confident at all

• Total Score” (Falls Efficacy Scale, in Lewis, p. 236.)

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Five Times Sit to Stand Test (FTSST)

Patient rises from a seated position five time in a row while being timed for speed.

(Whitney, SL, Wrisley, DM, Marchetti, GF, Gee, MA, Redfern, MS, and Furman, JM, Clinical Measurement of Sit-to-Stand Performance in people with Balance disorders: Validity of Data for

the Five-times-Sit-To- Stand Test. Phys Ther 2005;85(10):1034-1035)

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FTSST Normative Reference Values (seconds for 5 stands)

Whitney, 2005 Bohannon, 2006

Young controls23-57 yrs.

8.2 11.4 60-69 yrs

Young with balance 14-59 yrs

15.3 12.6 70-79

Older control63-84 yrs

13.4 12.7 80-89

Older with balance 61-90 yrs

16.4

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TIMED Up and Go Test (TUG)

• The examiner times how long it takes for patient to

• sit in a chair,

• rise,

• stand still,

• walk towards a wall,

• turn around

• before touching the wall,

• return to the chair and sit down. 135

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TIMED UP AND GO MEANS PUBLISHED FOR COMMUNITY ELDERLY (from Isles et al, p.1370)

AGE RANGE yrs. TIMED GET UP AND GO (secs)

20-29 5.3

30-39 5.4

40-49 6.2

50-59 6.4

60-69 7.2 (8,8.4,13)

70-79 8.5 (8.5,8,8.4)136

Interpreting TUG Test

• If it takes the person greater than 14 secs, they have high falls risk

(https://www.atrainceu.com/course-module/1473452-69)

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STEP TEST

• Measure the times a person can step with one foot completely on and off a 7.5cm block quickly in 15 seconds

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MEANS FOR STEP TEST (# in 15 seconds)(from Isles, et al, p. 1370, 2004)

AGE 20-29 30-39 40-49 50-59 60-69 70-79

Isles: mean in secs.

20.72 20.17 18.77 17.13 15.59 13.73

Others:HillBrauer

17.671615.6

17.671615.6

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LEARN MORE

• It is advised for practitioners who wish to work with elderly patients to train with skilled clinicians to gain valuable hands-on experience.

• Volunteer in a nursing home, hospital, or rehabilitation practice to learn how to work with elders

• Practitioners are encouraged to contribute to the research to demonstrate the long term outcomes of various massage interventions on impairments common to our aging population. 140

MASSAGE WORKS!www.educise.com

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CONCLUSION• Therapeutic massage is a valuable adjunct

intervention for improving functional outcomes and quality of life in older adults.

• Massage may be readily incorporated into a treatment program to promote mobility, circulation, relaxation, and balance, reduce pain, anxiety, tension, and agitation and improve sleep and quality of life for the elderly population.

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Author: Theresa A. Schmidt, DPT,MS,OCS,LMT,CEAS,DD

Dr. Schmidt is a Board-certified specialist in orthopedic physical therapy,

massage therapist, personal trainer, and certified ergonomic assessment

specialist. She is owner of Flex Physical Therapy in Long Island, NY, and

served as faculty of Physical Therapy at Touro College, acting Chair of the

Physical Therapist Assistant Program, and adjunct professor at CUNY

Queens College and Nassau Community Colleges. As President of Educise

Resources Inc., a professional continuing education company, she

presented for APTA, AOTA, AMTA, NYSSMMT, Fascia Research Congress,

NASA Inomedic, New Center for Wholistic Health Education, and private

hospitals. She graduated with Highest Honors from Long Island University’s

Physical Therapy Program: Brooklyn, NY, and received her Massage

Therapy diploma from the New Center for Wholistic Health Education. She

studied manual therapies including myofascial release, craniosacral therapy,

visceral manipulation, joint mobilization, functional orthopedics,

counterstrain, muscle energy, functional technique, acupressure, and

alternative biofield therapies in therapeutic touch, shamanism, Body

M.A.T.H., and IET. She is a graduate of the Doctorate of Physical Therapy

Program at University of New England. For information about Dr. Schmidt,

visit www.educise.com

Thank You from

Theresa A. Schmidt and

Educise Resources Inc.

For info contact: www.educise.com

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