By Barbara Cunningham
In part 1 of this article, the author reviewed Guillain-Barre Syndrome and presented the case of one woman who was struck with this disease
By Barbara Cunningham
In part 1 of this article, the author reviewed Guillain-Barre Syndrome and presented the case of one woman who was struck with this disease. The author then introduced Paul Lewis, an RMT who has developed an approach to treating patients who suffer from the disease that is very individualized, and takes into account its dynamic progression and the ever-changing needs of the patient. Part 2 will describe how Lewis dealt with the woman’s case, and how massage therapy enhanced her recovery period.
MASSAGE TREATMENT IN HOSPITAL
“It all happened so fast. The pain was unbearable and I required a wheelchair from the point of admission because I was too weak to even hold myself up,” says Cindy Cartwright, who found herself with Guillain-Barre Syndrome (GBS) in April 2010.
Within the next 24 hours, various medical tests were performed on Cindy, including an MRI, CT scan, bloodwork, X-rays, ultrasound, nerve conduction velocity studies (NCV) and a spinal tap (showing increased spinal fluid protein with a cell count exclusive to GBS) before the GBS diagnosis was made. Medical treatment for GBS began on April 28. This included plasmaphoresis, the most crucial function of which is to keep the patient’s body functioning during the initial recovery of the nervous system. Cindy was admitted into the intensive care unit (ICU) to monitor and assist as other GBS symptoms occurred. At this point, she was fully paralyzed in all her limbs and all organs up to the stomach area, and also experiencing slight paralysis in her face, around the mouth area, and loss of control of the swallowing reflex. In addition, she was unable to close her eyelids and was hooked up to feeding tubes and a urinary catheter.
To illustrate the dynamic progression of this disease, by May 12 Cindy’s body began to turn around and caregivers were immediately instructed to manually move her limbs. She notes that the last areas affected with the paralysis were the first to come back. Over the next week, she became able to close her eyes, then swallow, which allowed the feeding tubes to be removed.
In a few days, Cindy was moved out of ICU to a regular room where she began to receive massage therapy treatments from Paul Lewis, who had successfully executed a three-way consultation between Cindy, her doctor and himself.
“It is wise,” notes Lewis, “to receive the doctor’s acknowledgment before beginning massage therapy treatments in hospital.”
Physiotherapy was introduced shortly thereafter, as well. Lewis notes that he also incorporated a little reflexology along with the massage treatments from which Cindy reported considerable pain relief.
Each in-hospital massage therapy treatment session took from two to three hours. The length of time reflects the very slow pace necessary, as the patient is in unbearable pain and is still experiencing all the other aformentioned symptoms of GBS. The patient cannot move, but can certainly feel, and the sensation primarily registered is pain.
HOW MASSAGE THERAPY HELPS
The main premise behind incorporating massage therapy for this disease is that massage can influence the afferent neural pathways. When the Schwann cells are reproducing myelin to repair the myelin sheath, signals are either slow, absent or misdirected and registered as pain. In this instance, we can use what we know about dermatomes, move the muscles and joints and hope the body registers the signals as touch. It is almost, but not quite, as though the RMT manually sends the signals back to the brain so that the patient’s pain decreases.
Cindy was on high doses of morphine and blood thinners, she was in excruciating pain and she had not been actively moving. There was a high resting tension in her muscles, and diminished sensation in her limbs. Therefore, Lewis used slow passive relaxed movements to help with stiffness and mobility; and gentle muscle squeezing to create afferent response and try to optimize circulation and drainage while slowly moving the structure through its normal range of motion.
No hydrotherapy was used at this stage due to altered sensation and the inability to detect temperature. Also, very little lotion was employed. Joint mobilization was carried out to help maintain range of motion (ROM) and decrease pain. Adapted treatment protocols for TMJ were utilized, and treatment for constipation was included, as was attention to Thoracic outlet syndrome and Bell’s Palsy.
NOTES FROM THE RMT
For treating GBS patients, Paul Lewis calls attention to a number of factors that require thoughtful assessment and approach.
“You shouldn’t use deep pressure because the patient is on blood thinners, and always remember that pain medications cloud their feedback. Remember to wear gloves and follow other safety protocols while treating patients wearing medicated dermal patches.
“Be careful in repositioning the patient,” he notes. “In fact, don’t reposition the patient if it’s not necessary.”
“Use passive relaxation movements, and ensure your palpation skills are intact.”
“I looked at trying to maintain peripheral nerve system (PNS) pathways via soft pressure adapting to the tissue tone and structures, and by using a gentle form of Dynamic Angular Petrissage (DAP).”
MASSAGE TREATMENT AFTER DISCHARGE
In early June, Cindy was released from hospital to continue her rehabilitation as an outpatient. This included physiotherapy three times per week and massage therapy two times per week.
“Massage,” reported Cindy, “hurts for the first 45 minutes, but after the session, I feel good for four to five hours.”
Recovery was slow and very painful; however, the techniques used in the massage therapy sessions by Paul Lewis offered relief from the discomfort that Cindy was experiencing. This allowed her the flexibility to continue with the physiotherapy exercises, and meant she could take less pain medication. It also helped her relax so that she could sleep.
MORE RMT NOTES
“Dynamic Angular Petrissage™ involves using one hand to gently knead the muscle while using the other hand to take the limb through the ranges of motion according to the muscle’s line of pull, changing angles not only to simulate the action of the muscle but also to help refine the movements,” explains Paul Lewis, who also found this technique to be extremely gentle and helpful in Cindy’s case. “The other hand is gently adapting to the tissue’s texture, tone, tenderness and temperature while kneading the tissue. The kneading technique is determined by the target tissue.”
For example: “If I am working on the tibialis anterior, or just above the knee, I will use palm point kneading to protect the thumb and work around the knee area similar to GTO but with gentle kneading action so that I can address the quadriceps adductors hamstrings, and other leg muscles, following the direction of the fibers in order to determine if there is a high resting tension.
“Now if the band is really taut, I will follow the band and then bow to the left or right in order to help knead and loosen it up. There is a similar concept in Aikido redirecting a force that is coming straight at you to the right or left causing the force to weaken.”
At the five-month mark, Cindy had all but recovered, having residual numbness in her feet and hands. Her grip strength was not 100 per cent, yet, and she still experienced some fatigue, but she was happy to start exercising again.
She reported, “Massage still helps so much. Ideally massage every two or three days would be the best – every fourth day I am managing, but if I have to wait a week – it’s excruciating!”
CONCLUSION AND RESEARCH INITIATIVES
Although GBS often follows a viral illness, there is no evidence that the disorder can be transmitted from one person to another. In fact, often the virus or bacteria is no longer present in the patient when the peripheral nerve damage is developing. While the medical community investigates why only certain people develop GBS when millions of people are exposed to it’s identified triggers such as infections, viruses, surgery, and vaccines, we can continue our efforts to provide safe and effective massage therapy treatments for our GBS clients, thanks to the co-operation of client Cindy Cartwright and therapist Paul Lewis.
Lewis is planning to conduct more research to further explore the efficacy of massage therapy in the recovery process of GBS clients. His treatment plan suggestions for Guillain-Barre Syndrome should give other sufferers hope for a more comfortable and speedy recovery.
SOURCES USED FOR THIS ARTICLE
- Ashbury A.K., Hauser S.L. (2001). Guillain-Barre syndrome. In Braunwald E., Fauci A., Kasper D.L., et al. (Eds.), Harrison’s Principles of Internal Medicine (15th ed., pp. 2507-2509). New York: McGraw-Hill.
- GBS/CIDP Foundation International Summer 2009, The Communicator.
- National Institute for Neurological Disorders and Stroke. Guillain-Barre Syndrome Fact Sheet, 2009.
- Office of the Chief Science Officer for Disease Control and Prevention, Atlanta, Georgia 30333, USA (PHaber@cdc.gov).
- Porth, Carol Mattson. Pathophysiology Concepts of Altered Health States. 7th ed. Philadelphia, Pennsylvannia: Lippincott, 2005: 1204-1205.
- Rattray, Fiona and Linda Ludwig. Clinical Massage Therapy. Elora, Ontario: Talus Inc., 2000: 753-824.
- Tortora, Gerard J. and Bryan Derrickson. Principles of Anatomy and Physiology. 11th ed. New York: Wiley, 2006.
- Werner, Ruth. A Massage Therapist’s Guide to Pathology. 3rd ed. Baltimore, Maryland: Lippincott, 2005: 261-263.
Barbara Cunningham’s passion lies in research and writing for the profession of massage therapy. She works with Massage in Motion, and recently opened her own practice, called the Treatment Room, in Mississauga, Ontario. Her ultimate career goal is to see massage therapy become tax deductible from the first dollar. Barbara’s raison d’etre is her three children.