The following abstract, "Positive Systemic Effects Using Therapeutic Massage as a Conjunctive Treatment for Rheumatoid Arthritis," received bronze recognition from the Massage Therapy Foundation at the 2007 American Massage Therapy Association National Convention in Cincinnati. The abstract was submitted by Robin Anderson, CMT, NCTMB, who operates a private practice in the Northern Baltimore suburban region of Maryland. She is a guest massage instructor at her alma mater, the Community College of Baltimore County, and also has experience as an American Council on Exercise (ACE) certified personal trainer with special training in cancer recovery exercise programming, senior fitness and post-rehabilitative exercise. The abstract is reprinted here in its entirety. If you have a research abstract you would like to submit for possible publication in a future issue of Massage Today, please send an e-mail to editorial@massagetoday.com, with massage research abstract in the subject line.

Objective: This study considered the efficacy of causing positive systemic effects translating into sustained periods of symptomatic remission in the management of rheumatoid arthritis (RA) for a recently diagnosed patient.

Methods: The study subject reported RA complications with pain-related symptoms in the right shoulder, forearm and index finger. Over a 10-week period, the subject received 8 therapeutic massage sessions; 7 were weekly and one was at a 3 week interval. Each session lasted for 1 to 1½ hours and was mainly comprised of Swedish and myofascial techniques to the musculature surrounding the right glenohumeral joint with an additional specific hand massage protocol and light friction strokes in the right antecubital region to encourage lymph flow.

Results: At the third weekly session, the client reported experiencing no pain or discomfort. This period of non-flare up and absence of pain continued through the remainder of the study period, even with a longer 3 week duration between sessions at the end of the 10 weeks. The client also noted that no pain medication other than her weekly Methotrexate dosage was taken throughout the duration of the study and that she obtained a better quality of sleep and daily activity.

Conclusion: Therapeutic massage treatments, while able to achieve qualitative muscle release in an affected joint region, can also positively affect the physiological systems of a patient with RA and help to alleviate and prolong the deteriorating effects of the disease.

Introduction

Autoimmune diseases are noted for their deteriorative properties of physiological systems as a faulty immune response (Werner, 2005). The functionality of the circulatory system and the presence of persistent stress levels can have a negative impact on circulation, triggering pathogen invasion and producing symptomatic pain, discomfort and inevitable decline consistent with the progressive nature of this disease classification. Massage therapy has the ability to significantly affect systemic disorders because of its applicable methodology: the promotion of detoxification through vasodilation to assist in the removal of toxins, which can cause pain responses; the improvement of overall circulation by encouraging blood and lymph flow; the activation of the parasympathetic nervous system division by lowering blood pressure, heart rate and respiration rate inducing relaxation and stress reduction (Prekumar, 2004; O'Brien, n.d.). Massage therapy, when used in conjunction with other prescribed treatments, can have a positive systemic effect in the management of the symptoms and progression of an autoimmune disorder.

Rheumatoid arthritis (RA) affects the structural integrity and function of musculoskeletal joints and eventually the entire body (Osborn, 2005). The immune system mistakenly attacks the membranes and joint structures via the accumulation and stagnation of synovial fluids, initiating inflammation, pain and loss of function, called articular degeneration (Lowe, 2006). RA in its progressive stages will damage other structures and organs such as blood vessels, lungs and the pericardium. Once diagnosed, patients generally spend their lifetime using traditional and alternative therapies attempting to manage and decelerate the debilitation process (Werner, 2005).

Signs and symptoms are prominent morning stiffness and joint swelling, tenderness and pain. The distinctions associated with RA are the tendency to first affect the interphalangeal and metacarpophalangeal joints of the fingers/hands and toes/feet, as well as cause entrapment syndromes of nerves near affected joints such as the median nerve at the carpal tunnel. The development of subcutaneous nodules on protuberances of bones, bursae and tendon sheaths are also notable (Papadakis and McPhee, 2006).

The current approach to treatment is to attempt to stall or interrupt the inflammatory symptoms (known as flare-ups) associated with the advancement of joint deterioration, minimize the occurrences of intense pain episodes and decreased joint mobility, and subside the condition into a remission phase. A pyramid approach has been developed to determine the level of therapeutic intervention. At the base of the pyramid, the "first line" of drugs and therapies are suggested such as rest, exercise and non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids (i.e., Prednisone). When the first line loses its efficacy, a "second line" is employed, which depending on the drug, increases risk of toxicity based on dosage and prolonged usage. These cytotoxic drugs are called slow-acting anti-rheumatic drugs (SAARDs) (i.e., Methotrexate), and are sometimes used in conjunction with a first line drug upon early diagnosis of RA. This sometimes is very effective but also is known to cause some notable side effects from the usage duration. Physical therapy, therapeutic devices and joint replacement surgeries are mechanical measures used in conjunction with the drug pyramid. Ultimately, present methods are devised to provide pain relief, decrease joint inflammation and to maintain and restore joint functionality preventing further bone and cartilage deterioration (Schumacher, Klippel and Koopman, 1993). It is logical to deduce that using massage therapy treatment can positively affect RA with similarly noted therapeutic goals.

A recent study at the Touch Research Institute in Miami on the effects of hand massage in arthritis patients demonstrates this premise. Through the use of wringing, skin rolling, circular, and friction type strokes, Dr. Field substantiates by measuring grip strength pre and post treatment that the treatment group realized a significant improvement in mobility and function in comparison to the control group which did not receive massage therapy (Field, et al., 2006). Moreover, to increase formation and flow of synovial fluid in affected joints, treating the surrounding joint tissues with light friction and vibration and establishing a methodical treatment interval is suggested (Wine, 1995). Since RA is a systemic disease, it can also create blockage in lymph nodes proximal to affected joints and thereby contributing to discomfort and pain experienced by the patient. The aforementioned gentle circular friction techniques have been used to help increase the delivery of oxygen and nutrients and assist in the removal of waste products surrounding the affected joints (Osborn, 2005). When the joint is in an acute inflammatory stage, massage is contraindicated. However, when in remission, massage can effectively manage symptoms, prevent inflammation, and reduce joint damage (Lowe, 2006).

Methods

Client Profile: A 39-year-old female dental hygienist, married and the mother of three children, presented with pain and discomfort in her right shoulder and second (index) finger joints. She recently was diagnosed with RA after enduring nearly eight months of a constant "flare-up" condition, describing symptoms of dull, achy pain throughout her entire body causing difficulty in mobility, particularly in the morning hours, and reduction in the ability to perform daily tasks at work and home; the client also stated that she experienced visible swelling in the noted joints, additionally, in the knees and feet, with the right side seemingly more affected. Medical examination by her primary care physician and a rheumatologist, and medical testing of X-rays and blood work, indicating high levels of rheumatoid factor, resulted in her definitive diagnosis in May 2006. The client was prescribed two medications, a "first line" corticosteroid in conjunction with a "second-line" SAARD, to manage her condition - Prednisone, 5 mg each dosage, two doses per day, to address the long-term constant pain condition she had been enduring, and a 7.5 mg dosage of Methotrexate, was taken weekly. After the initial flare-up alleviated, she was instructed to take Prednisone only when a flare-up recurred.

The client reported that since her diagnosis and starting the prescribed medication, her flare-ups were unpredictable and sporadic, lasting approximately 1-2 days in occurrence. Activities that triggered flare-ups included excessive periods of walking, standing or performing household chores and activities which caused overexertion or fatigue. Other secondary factors that may have exacerbated her RA condition were repetitive occupational activities, family environment and overall daily stress levels. As an addendum of historical interest, she was a baton twirler for 10 years as a child and may have sustained some structural injury in her fingers, hands, wrists and arms. She also noted a previously unpleasant massage experience.

Treatment Plan

Overview: The 10-week study consisted of the following elements: initial baseline assessment and client interview, 7 weekly treatment sessions at exact 7 day intervals, and one final treatment session (for a total of 8 treatments) after a 3-week period with a reassessment and concluding client interview. Each treatment session was 1 - 1½ hours in length. A postural assessment with photographs and range of motion testing using a goniometer were performed to document any asymmetries corresponding to the RA affected joints and to obtain comparative data on the functionality between left and right shoulder joints (Andrade and Clifford, 2001). Measurements were taken in the following planes of motions: shoulder flexion, extension, abduction and lateral and medial rotation, in both standing and supine position. The client filled out a weekly log sheet with personal descriptive comments prior to treatment and reported any flare-ups from the previous week, immediately following treatment, hours after treatment and daily progress during the week until the next session. Elements of statistical significance included a pain rating scale with 1 as the lowest and 10 as the highest, description of daily activities, indication of flare-up and subjective comments. Number of hours of sleep was also noted. At the conclusion of the 10 weeks, data from pre and post treatment assessments and subjective commentary were analyzed.

Plan and Techniques: The primary objectives were to affect the systemic conditions associated with RA. If it is conclusively determined that the massage treatments were positively affecting and managing her condition, then the client could potentially explore the adjustment of medication dosages to lower levels with the advisement of her rheumatologist, and utilize massage at a regular treatment interval to help regain some mobility and thereby, enhancing her overall quality of life (i.e., desire to exercise again, maintaining more active lifestyle, ability to manage stress more effectively, and have fewer physical limitations) and delay the deterioratory elements associated with RA.

Given the data obtained in the client interview, the treatment plan was structured based on a series of factors. Since the client had a previously unpleasant experience with massage, it was important to establish a gauging presence of touch to dispel any previous apprehension. Secondly, palpation of surrounding joint tissues and structures and their responses to certain techniques dictated treatment planning. The client's ability to achieve a relaxed state during treatment also influenced the plan. Finally, once trust in the student therapist was established, specific treatment protocols used with RA and related muscle tension were utilized. The following illustrates an overview of treatments:

Session 1: Acclimation of touch sensitivity, palpation of structures and experimentation of Swedish, deep-tissue tools and myofascial release techniques. Achievement of relaxation state.

Session 2: Began to affect systemically through Swedish massage and utilized/reinforced myofascial and/or deep-tissue releases found effective in Session 1.

Sessions 3-8: Employed specified hand massage technique utilized in Touch Research Institute study (Field, et al., 2006), friction and compression strokes to cleanse the affected bursa in the right shoulder and right index finger, continued effective myofascial releases (Andrade and Clifford, 2001) in surrounding muscles of the affected joints, and relaxation with Swedish techniques, friction strokes at strategic lymph drainage/node location to encourage better lymph flow.

Clinical Visits: The first session established the baseline treatment, palpation of structures and experimentation with massage techniques. Swedish techniques were used in an effort to cause relaxation and establish trust and intention with the client. The palpation of the muscular structures in the glenohumeral joint of the right shoulder and the metacarpophalangeal joints of the right index finger indicated that the cervical and forearm areas held significant tension and discomfort, specifically, the short head of the biceps brachii, deltoid, pectoralis minor, scalene and levator scapulae. The lower right leg in the posterior compartment had ischemic knots in the gastrocnemius and soleus muscles proximal to the Achilles tendon attachments, which suggested that joint discomfort may have caused some additional compensatory patterns in her posture and gait. Observation of the client's relaxation during treatment was also noted for future treatments. Deep-tissue tools and myofascial- release techniques were employed to test effectiveness and client tolerance; her muscular structures responded minimally to myofascial release and therefore, the use of deep tissue techniques (to the client's tolerance level) were used to address muscle tension.

The second treatment session began the first phase of actual treatment that addressed her RA condition. Since the right shoulder area seemed to be a source of great tension and imbalance, it was initially targeted as a starting point. An effective shoulder release would theoretically cause the other affected joints to eventually subside their corresponding tension. Techniques used were myofascial gross and focused stretches on the deltoid (separated into anterior, middle, and posterior segments), biceps brachii (separating the long and short heads), triceps brachii (separating each muscle head), and upper trapezius; myofascial cranial base, levator scapulae, and scalene (anterior, middle, and posterior) stretches; and effleurage and petrissage strokes for warming up and moving tissues. These applications opened up the upper thoracic and cervical areas as the muscles seemed much more receptive to myofascial release and deep tissue techniques this time. Subsequent sessions allowed for continuation of myofascial work. The massage techniques used in the study performed at the Touch Research Institute were incorporated into the remaining sessions to directly treat the metacarpophalangeal joints of the right index finger. This technique begins with effleurage-like strokes starting at the wrist then moving superiorly to the elbow and then inferiorly along the sides of the affected forearm; a wringing motion is then applied to the same forearm area; a circular back and forth motion using the thumb and forefinger is used to cover the entire forearm, hand and the specific affected joints; then skin rolling is performed using the thumb and forefinger across the hand laterally to medially, then moving superiorly up both sides of the forearm to the elbow/antecubital area; a final effleurage was used as a closing/transition stroke (Field, et al., 2006). To stimulate fluid production within the bursa of the right shoulder, circular friction strokes were utilized around the affected area and compressive pressure and minimal rotation movement from the olecranon process superiorly to the head of humerus were used to gently massage the inside of the glenohumeral bursa. Circular friction strokes were used on the lateral and medial sides of the antecubital space to target the lymph nodes in an effort to get lymph flowing more freely.

Results

A reasonable degree of relaxation and trust in touch was progressively reached by the client at each session. This was indicated by her ticklish sensations in the triceps that presented in later sessions that were not initially evident. Commentary review from the client's daily logs and SOAP notes showed an overall positive satisfaction. Additionally, subjective visual observation of her posture and gait when she arrived for her appointments displayed noticeable improvement with each passing week. The elevation change in her arm/hand positions at the mid thigh were exhibited, the arm/hands appeared more level, equating to relieved tension in the shoulder joints. While increased mobility was realized in left shoulder flexion and abduction (21 to 25 degrees increase) in the erect positions, the right RA affected shoulder showed notable corresponding gains in the same motion planes; this indicates that the client may have been restricting motion patterns on the opposing left joint in compensation for experienced pain or discomfort from the right RA affected side. Supine measurements in both shoulders showed statistically similar changes in mobility. Supportive data was also found in the client's log sheets. At the beginning of the study period, the client reported experiencing joint pain as high as a 7 on the rating scale. Further review showed that the client reported no pain (0) for a period of 38 days towards the latter end of the study. This notable drop in the pain rating and non-occurrence of flare-ups bears significance proving the positive systemic and overall life quality effects of massage as a conjunctive therapy to her medications. While number of hours of sleep was recorded, since the client regularly obtained an average of 7-8 hours each night, it was not a contributing factor to outcome.

Discussion

The study data strongly support using massage as a conjunctive therapeutic treatment in RA cases. In just a 10-week period, this client was able to realize a state of nullified pain in her RA-affected joints and achieve a virtual remission status. It is apparent that the weekly treatment interval was effective in order to cause systemic changes and physiological response. Once a positive response was elicited, the client was able to achieve longer pain-free periods toward the end of study, indicating a readiness to transition into a maintenance level for massage treatment. It is not specifically clear what elements were most effective during the treatment process (i.e., strokes used, achievement of musculature releases in surrounding joint areas, or direct massage on the affected joint[s]); however, the overall improvement of joint functionality shows that incorporating massage treatment directly to affected joints using applicable portions of documented protocols (Field, et al., 2006; Andrade and Clifford, 2001; Wine, 1995) further demonstrates the success of these techniques. Generally, the use of massage therapy achieved a favorable systemic outcome. These results also suggest that regular massage therapy treatments bear further scrutiny in relation to prescription medication usage. With regards to this client's prescriptions, she had not taken one Prednisone dosage since the commencement of this study. Given the potentially damaging side effects of Methotrexate usage in the long term, if her rheumatologist is satisfied with these documented outcomes, then consideration to mildly reduce the dosage and/or types of medications used when regular massage sessions are maintained conjunctively as part of her overall disease management regimen is warranted. Further research in measuring blood levels to determine other systemic effects would be ideal.

Acknowledgements

The author would like to acknowledge Beverly Hamilton, CMT, and Jamiel Hafiz, CMT, for their supervision, guidance and instruction throughout the course of this case study. She would also like to recognize Dr. Tiffany Field and her colleagues from the Touch Research Institute at the University of Miami for granting access to their hand arthritis research prior to publication. A special acknowledgement to Theodora Welsh, CMT/MLD, for the tremendous educational opportunity to allow this research study to be conducted and selected to represent the Massage Therapy Program at the Community College of Baltimore County.

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