Parkinson’s and massage
Parkinson’s disease (PD) is a complex, chronic, neurodegenerative disorder affecting the central nervous system; it progressively results in severe disability impacting on the quality of life for those diagnosed (Craig et a. 2006; Tornhage et al., 2013; Donoyama et al. 2014; Casciaro, 2016). Currently, modern medicine is unable to find a cure, yet many patients diagnosed with the condition are able to manage it with various pharmacological approaches and alleviate the symptoms through alternative therapies, such as massage. So how does massage help those living with the condition and how, as therapists, can we provide the best care for PD clients?
Symptoms of PD and the state of current research
Some therapists may be unaware of the complex and innumerable array of symptoms that their PD client may present with; arming yourself with what to expect and how to safely treat can make a therapist an invaluable asset to the client. Symptoms of PD present as motor and cognitive impairments, as well as other non-motor symptoms such as pain, depression, fatigue, anxiety, apathy, autonomic nervous dysfunction and disturbances in sleep (Craig et al., 2006; Bega et al., 2014; Donoyama et al. 2014).
The three cardinal features of the condition include:
- rigidity (resistance to motion);
- resting tremor (shaking which is apparent at rest but which slows or stops with intentional movement); and
- bradykinesia (slow movement which makes walking more difficult and energy/time-consuming), with postural instability arguably a fourth cardinal feature (Donoyama et al. 2014; Casciaro, 2016).
The cause of PD is largely unknown, but it is triggered by an accumulation of certain protein bodies and the degeneration and loss of dopamine- producing cells in parts of the brain (Bega et al., 2014). A combination of medications, such as Levodopa, are used to treat PD; however, nothing has been proven to completely stop the progression of the disease (Casciaro, 2016). As such, many PD patients turn to alternative therapies, such as massage to complement their treatment in an attempt to alleviate symptoms of pain and rigidity and empower themselves to be active participants in their treatment (Bega et al., 2014; Casciaro, 2016).
Many PD clients report transient improvement in stiffness, posture and gait following massage therapy, which subsequently improves their self-confidence and well-being (Paterson et al., 2005; Bega et al., 2014). Unlike exercise, which is now well-established and integral in the management of PD (Bega et al., 2014), the research on the efficacy of alternative approaches, such as massage, is rather limited. Despite this limit in the number of quality studies that have specifically looked at PD and massage, the results from these are promising:
- Hernandez-Reif et al., (2002) compared massage to progressive muscle relaxation (PMR) and found the effects of massage superior to PMR, with benefits including improved sleep, decreased levels of stress hormones and increased independence in activities of daily living (ADLs).
- Paterson et al. (2005) looked at a combination of massage with homecare stretching exercises and found that patients reported improvement in their gait, movement in their extremities and performance in ADLs. Additional to these improvements, patients stated that they had increased confidence and overall sense of well-being and general improvement in their quality of life. These benefits persisted for weeks after the cessation of the investigation.
- Casciaro (2016) used a case-study approach to explore in detail the subjective benefits of massage treatment. The use of ‘deep longitudinal stroking, muscle squeezing techniques, passive range of motion movements, and general relaxation techniques’ were employed and had a positive effect on the client, reducing resting and postural tremor (Casciaro, 2016). Rigidity was also found to decrease during treatment, but this did not carry through beyond the treatment (Casciaro, 2016). In general, massage creates a relaxing environment that can decrease the activity of the sympathetic nervous system, which can help to reduce rigidity. This could help explain why the decrease in rigidity was not felt beyond the treatment as the sympathetic nervous system would have been reengaged when the client then had to resume and engage in everyday tasks.
The benefits of massage and what massage techniques work best:
Although the results from this particular case-study are very subjective and any conclusions cannot be applied universally, what it does effectively detail is the method of massage delivery, which is often lacking in larger controlled comparison trials. This detail is crucial for massage therapists unsure how to best treat their client with PD.
The author describes the treatment as being performed ‘proximally to distally with slow, deep continuous strokes, coupled with slow, smooth passive range of motion (PROM) exercises and stretching’ (Casciaro, 2016). The therapist also performed frictions at the origins and insertions of the client’s spastic muscles in order to reduce spasticity (Casciaro, 2016). This information is helpful for therapists unsure how to approach a client diagnosed with PD. Application of heat is also suggested as being an effective approach to encourage the pliability of muscle tissue, in particular to treat contractures that have resulted from rigidity and resting tremor (Casciaro, 2016). The author states that because it was a case-study investigation with no control, that it is difficult to say whether it was the effect of massage alone or more the relaxed state that the client experienced that resulted in the benefits reported. Numerous studies however have compared various massage treatments with purely relaxation-focused treatments in order to delineate the effects of physical touch with the induced states of relaxation (Craig et al., 2006; Donoyama et al., 2014; Tornhage et al., 2013). Any decrease in stress hormones (cortisol levels) or improvements in tremor, anxiety, muscle stiffness and pain were found to be greater in the massage treatment groups compared to the relaxation-only groups.
So how does massage actually create these benefits? Much of the gains can be related to the benefits of touch, as was discussed in the previous blog. A more physiological explanation can also be that massage dilates the superficial blood vessels near our skin, increases the rate of blood flow and improves venous return, the effects of which are beneficial to fatigued and contracted muscles, reducing the discomfort associated with muscle spasms and rigidity (Donoyama et al., 2014). The motor symptoms such as bradykinesia, resting tremor etc., are the result of the degeneration of the dopamine-producing cells; massage increases dopamine levels and as such could contribute to the perceived benefits experienced by PD clients (Donoyama et al., 2014). A study looking at Thai massage techniques suggest that massage stimulates the parasympathetic nervous system and superficial tissues which aid in alleviating muscle spasms, increasing circulation, reducing adhesions and promoting relaxation, which ultimately results in reduced fatigue, improved strength in the muscles and perhaps most importantly, reduced pain (Miyahara et al., 2018).
Contraindications of massage:
There are contraindications that therapists need to be aware of, specifically extremes of temperature if the PD client has any hypertension, and conversely the therapist needs to be aware that hypotension (as a result of many PD medications) can result in a patient experiencing dizziness or requiring assistance once the treatment is finished (Casciaro, 2016).
Any painful or prolonged aggressive techniques should be avoided as these are not the best in promoting rest and relaxation, and as discussed, some of the benefits of massage can be attributed to the relaxed state it invariably induces, coupled with the benefits of touch.
Take home message:
Although data is limited, what the research does indicate is that massage is capable of improving some of the physical symptoms of PD, albeit transiently. More importantly, massage can assist in improving the mood, quality of life and self-efficacy for PD patients. This is vital, as the loss of control felt by those diagnosed can be more overwhelming than the physical symptoms themselves. Massage therapists can assist in managing and alleviating the discomfort and pain experienced; what we need is more quality research to back up the plethora of anecdotal evidence out there.
Ready to find out more?
Bega, D., Gonzalez-Latapi, P., Zadikoff, C., & Simuni, T. (2014). A Review of the Clinical Evidence for Complementary and Alternative Therapies in Parkinson’s Disease. Current Treatment Options in Neurology, 16(10), 314. https://doi.org/10.1007/s11940-014-0314-5
Casciaro, Y. (2016). Massage Therapy Treatment and Outcomes for a Patient with Parkinson’s Disease: A Case Report. International Journal of Therapeutic Massage & Bodywork: Research, Education, & Practice, 9(1), 11–18. https://doi.org/10.3822/ijtmb.v9i1.287
Craig, L. H., Svircev, A., Haber, M., & Juncos, J. L. (2006). Controlled pilot study of the effects of neuromuscular therapy in patients with Parkinson’s disease. Movement Disorders, 21(12), 2127–2133. https://doi.org/10.1002/mds.21132
Donoyama, N., Suoh, S., & Ohkoshi, N. (2014). Effectiveness of Anma massage therapy in alleviating physical symptoms in outpatients with Parkinson’s disease: A before-after study. Complementary Therapies in Clinical Practice, 20(4), 251–261. https://doi.org/10.1016/j.ctcp.2014.07.010
Hernandez-Reif, M., Field, T., Largie, S., Cullen, C., Beutler, J., Sanders, C., Weiner, W., Rodriguez-Bateman, D., Zelaya, L., Schanber, S., & Kuhn, C. (2002). Parkinson’s disease symptoms are differentially affected by massage therapy vs. progressive muscle relaxation: A pilot study. Journal of Bodywork and Movement Therapies, 6(3), 177–182. https://doi.org/10.1054/jbmt.2002.0282
Paterson, C., A Allen, J., Browning, M., Barlow, G., & Ewings, P. (2005). A pilot study of therapeutic massage for people with Parkinson’s disease: The added value of user involvement. Complementary Therapies in Clinical Practice, 11(3), 161–171. https://doi.org/10.1016/j.ctcp.2004.12.008
Törnhage, C.-J., Skogar, Ö., Borg, A., Larsson, B., Robertsson, L., Andersson, L., Backström, P., Fall, P.-A., Hallgren, G., Bringer, B., Carlsson, M., Lennartsson, U. B., Sandbjörk, H., & Lökk, J. (2013). Short- and long-term effects of tactile massage on salivary cortisol concentrations in Parkinson’s disease: A randomised controlled pilot study. BMC Complementary and Alternative Medicine; London, 13, 357. http://dx.doi.org.dbgw.lis.curtin.edu.au/10.1186/1472-6882-13-357