One in four adult Americans has been diagnosed with some form of arthritis — and so massage and arthritis is a topic that will become more important for therapists.
According to the Centers for Disease Control and Prevention, more than 54 million Americans have arthritis, and more than one in four adults with arthritis suffer from severe pain. Arthritis limits many adults’ everyday activities and doubling their risk for fall-related injury.
Arthritis has become the most common form of disability.
Arthritis is also one of the earliest-documented health conditions on Earth. Evidence of joint degeneration—osteoarthritis—has been documented in dinosaur skeletons that may be 70 million years old. Pre-Columbian remains from around 4,500 BC reveal symmetrical joint erosion, and ayurvedic texts dating from 123 AD describe a disease with joint pain, stiffness and fevers—rheumatoid arthritis.
Prevalence increases with age so that, with the elder population expected to skyrocket in coming decades (by 2030, one in five Americans will be over 65), the human and societal cost of arthritis may become overwhelming.
Of all forms of arthritis, osteoarthritis and rheumatoid arthritis are the most commonly experienced among massage therapy clients.
Massage and Arthritis: Osteoarthritis
Osteoarthritis is by far the most commonly diagnosed form of arthritis, affecting 30 million American adults, according to the U.S. Centers for Disease Control & Prevention. As soon as we begin standing, we place wear and tear on joints, over time eroding joint cartilage.
By the time we’ve reached the age of 40, most of us already show signs of degeneration in the cartilage discs between vertebrae.
Certain risk factors for developing osteoarthritis, such as excess body weight and sedentary lifestyle, joint injuries, weak postural muscles and repetitive joint strain, are somewhat controllable; others—age, gender (women are more often affected), and family history—are not.
Classic osteoarthritis symptoms are pain, stiffness and local inflammation, most often unilateral and in dominant-side joints in the hands or at weight-bearing joints in the spine, hip or knee.
The typical progression begins with erosion of cartilage and the ends of articulating bones at an affected joint, causing chronic inflammation and formation of bone spurs. Sometimes, tiny chunks of bone or cartilage break off and migrate, causing pain and inflammation elsewhere.
Chronic inflammation results in cytokine development and enzymatic action, which further damage the joint. As cartilage becomes totally eroded, bone ends eventually rub directly against each other, intensifying pain and inflammation.
Once thought to be progressive and irreversible, research into osteoarthritis has shown that cartilage remains metabolically active even into advanced age, so that it can, in fact, continue to remodel and repair itself. Even so, a client with osteoarthritis is likely to be taking multiple prescribed and over-the-counter oral medications such as non-opioid analgesics, anti-inflammatory drugs (sometimes prepared in combination with an analgesic), and an antidepressant approved to treat chronic pain.
Oral medications are often supplemented by over-the-counter topical ointments, creams or gels that may contain salicylates, herbal counterirritants, NSAIDs, capsaicin or cannabis. Some clients may use a transdermal patch, suffused with a local anesthetic, and a nutritional supplement such as combined glucosamine and chondroitin or fish oil.
Medical treatments range from injection of a corticosteroid or a synthetic lubricant directly into an affected joint, to replacement of damaged joint parts with plastic or metal parts, surgical realignment of the knee to shift body weight away from the deteriorated aspect of the joint. Some people require total hip or knee replacement. Shoulder joint replacement may reverse the orientation of the glenoid fossa, providing greater stability.
Massage and Arthritis: Rheumatoid arthritis
In contrast to osteoarthritis, rheumatoid arthritis is autoimmune. In a case of mistaken identity, the body’s immune system identifies synovial membrane tissue as a pathenogenic invader, and attacks it.
As with most autoimmune conditions, there appears to be a genetic predisposition that, when coupled with a viral or bacterial trigger such as strep throat, initiates the autoimmune response.
In one theory, the resemblance of streptococcus bacterium to the cellular structure of synovial membrane facilitates the attack: Having previously encountered and defeated streptococcus, the immune system responds to what appears to be a subsequent invasion.
Risk factors for developing rheumatoid arthritis are those for many other autoimmune conditions: age (typically, 40 to 60 years old), gender (women are vastly more often affected) and family history. Obesity, smoking and environmental exposure to contaminants such as asbestos and silica are also considered risk factors.
Joint pain and inflammation tend to be bilateral in the rheumatoid arthritis sufferer, affecting smaller joints in the hands and feet first, and then spreading to knees, elbows and hips. Symptoms tend to be worse when first rising in the morning, and following physical exertion. For nearly half of those with rheumatoid arthritis, non-joint structures such as skin, eyes and salivary glands, as well as nerve tissue, bone marrow and blood vessels, and organs such as the heart, kidneys and lungs, are also affected.
Rheumatoid arthritis shares other characteristics with most autoimmune conditions: fevers, fatigue and weight loss, plus periods of relapse (called flares or acute phases) and remission (called subacute phases).
It is during the flares that structural damage occurs, causing joints to become progressively deformed and unstable. Rheumatic nodules may form on the dorsal aspect of the hands, progressively limiting hand dexterity, and an abnormal proportion of adipose tissue for the person’s overall body mass index may develop.
A client with rheumatoid arthritis may be taking a range of prescribed medications to relieve pain, such as non-opioid analgesics, and drugs that inhibit the autoimmune response, including corticosteroids, disease-modifying antirheumatics, disease-modifying antirheumatics combined with methotrexate, a powerful immunomodulator, and other drugs that act on the immune system, such as TNF-alpha inhibitors.
In addition to prescribed medications, some rheumatoid arthritis clients may take nutritional supplements such as fish oil, or plant oils such as evening primrose or borage, or black currant seeds that contain a type of fatty acid that may alleviate morning joint pain and stiffness.
Medical treatments for rheumatoid arthritis include surgeries such as synovectomy, which removes inflamed synovial tissue and associated debris; procedures to repair tendons and ligaments; fusion or realignment of joints, and replacement of joint parts with plastic or metal prostheses.
Both rheumatoid arthritis itself and the traditional medications used to treat it compromise resistance to infection, increasing the risk for developing opportunistic infections, a subsequent autoimmune condition such as Sjögren syndrome, and for osteoporosis, carpal tunnel syndrome, atherosclerosis, pericarditis, lung infections and lung scarring.
Massage and Arthritis: How it Helps
Massage is the complementary treatment most often recommended to arthritis patients by traditional medical practitioners. The pain and joint stiffness of any of the types of arthritis just described may be the most common reason why many clients first try massage therapy.
Treatment planning for clients with arthritis begins by ensuring that the treatment space is designed to accommodate these clients’ degree of mobility and function.
Adequate ambient lighting and uncluttered walkways without area rugs help to reduce fall risk. Easy-to-operate doorknobs and light switches, along with grab bars and elevated toilet seats, allow safe, easy movement throughout the treatment space. Easy-to-grasp pens facilitate completing the health history forms.
Planning comfortable and effective massage treatment for a client with any form of arthritis includes identifying cautions and contraindications, therapeutic intentions, assessments, medications and possible side effects, and appropriate positioning, draping and bolstering.
• Cautions and contraindications: Avoid over-working areas that have recently been inflamed; monitor the client’s ability to provide accurate feedback about pain, pressure and temperature; and ensure a narrow temperature range when using thermotherapies.
Strokes with circulatory intent are contraindicated on and distal to inflamed joints, and vigorous range of motion at affected joints should be avoided. Massage should be deferred for a client in acute pain, or who has fever or other signs of a flare.
• Therapeutic intentions: Massage can temporarily relieve pain, reduce the effects of stress, maintain joint range of motion, encourage restorative sleep, and alleviate certain medication side effects.
Which modalities you and your client agree on using to reach these goals depends on the skills you have available and which modalities are best for your client’s overall case management. Appropriate options include Swedish massage with gentle range-of-motion techniques, thermotherapy, and during periods of flare, minimal-touch modalities such as craniosacral therapy and reiki.
• Assessments: Discuss pain and medical treatment side effects, and assess signs of inflammation, fever or other signs of flare such as extreme fatigue or malaise. In order to identify appropriate modalities and techniques, evaluate joint range of motion and degree of mobility, along with postural compensations and gait dysfunctions.
• Medications and side effects: Ask about all prescribed and over-the-counter medications and nutritional supplements, and dosage changes since the prior massage treatment; discuss possible changes in or emergence of side effects. Investigate whether or not medications may interfere with perception of sensation or with immune system functioning. Be mindful that a client taking an analgesic drug is unable to provide accurate feedback regarding pain, pressure and temperature.
Because a client taking a drug that suppresses the immune system is at greater risk for infection, take care to follow Standard Precautions for the prevention of pathogen transmission, and defer massage if you or a family member has been exposed to an infection.
Techniques such as rocking and jostling may worsen medication-caused nausea or dizziness, and massage of the abdomen may alleviate medication-caused constipation.
Advise each client, however, that although massage may temporarily relieve such medication side effects, they will no doubt return, for as long as the causative medication is taken.
• Positioning, draping and bolstering: Involve the client in choosing the position of greatest comfort. Use the client’s degree of mobility to decide whether the difficulty of turning over and repositioning eliminates any benefit to the client of doing so.
Following shoulder or hip realignment or replacement surgery, avoid side-lying positioning on the affected side. Soft pillows in place of formed bolsters may be more comfortable following knee realignment or replacement surgery. Elevate inflamed structures, unless otherwise contraindicated.
Be prepared to assist the client onto and off the massage table and, occasionally, to assist with buttons, zippers and belts. Above all, be gentle when moving the limbs of a client who has arthritis, and mindful that, for these clients, less is almost always more.
Massage and Arthritis: Future clients
As the U.S. population ages, the prevalence of age-related conditions such as arthritis will increase. When a client asks, “Does massage help arthritis?” Be sure to have the answer — and be prepared to address this clientele by obtaining appropriate training, and by designing your sessions to meet the needs of the client who lives with osteoarthritis or rheumatoid arthritis.
Julie Goodwin, LMT, is an author, bodywork educator, National Certification Board for Therapeutic Massage & Bodywork-approved provider and creator of TxPlanner.org (txplanner.org). Her more-than-30-year massage practice focused on elders and people in treatment for cancer. She is the 2016 Alliance for Massage Therapy Education Educator of the Year. Her articles for MASSAGE Magazine include “More Americans Have Dementia. This is How Massage Can Help.”