Issue link: https://www.massageandbodyworkdigital.com/i/72103
• Cervical dystonia. Also called spasmodic torticollis, this condition involves painful unilateral involuntary contractions of the sternocleidomastoid and other neck rotators. • Vocal dysphonia. This involves involuntary contractions of the muscles that control the vocal cords, leading to problems with speech. • Migraines. Chronic migraine appears to respond well to injections of botulinum toxin. It has also been studied for chronic tension-type headache, but the results were not consistently better than alternative options. • Axillary and palmar hyperhydrosis. Multiple tiny injections to the skin where sweat glands are overactive can reduce sweating for several months at a time. • Muscle-related pain. People who have pain related to involuntary spasm can benefit from injections that limit muscle tone. New research and manipulation of the toxin holds promise for other pain- related applications as well. Other applications are common but less well-studied, including its use for spasticity related to cerebral palsy, Charcot-Marie Tooth syndrome, multiple sclerosis, stroke, and others. One generous person shared his experiences with me—while he found some relief from leg spasms with his injections, the trade-off was intense muscle weakness. BOTOX AND MASSAGE— ALLIES OR ADVERSARIES? Most applications of botulinum toxin occur without major adverse effects, but while complications are rare, they are not unheard of. According to the FDA, symptoms of botulism poisoning can occur if the treatment protocol is wrong, or—and here is where massage therapists should be alert—if the solution seeps out of the intended treatment area. The promotional material distributed for cosmetic applications of Botox suggests that the full effect of cosmetic injections may not be achieved for several days after treatment. The patient is encouraged to gently exercise facial muscles immediately, but not to touch, compress, sleep on, or otherwise disrupt the injection sites for a minimum of four hours after treatment, in order to avoid spreading the toxin to unintended areas. This includes facial manipulation with massage as well, and massage elsewhere on the body must be conducted without putting the client face down in the cradle—otherwise the postmassage "table face" that many of us experience may last a lot longer than usual. So it seems clear that massage and Botox are not good partners, because manipulation of treated areas may decrease the desired action at the targeted spot and increase undesired action in surrounding tissues. This makes sense for cosmetic applications. However, some research suggests that the toxin, when injected into deeper muscles, may work better if the tissues are carefully manipulated to improve its uptake. For our clients who use Botox for therapeutic rather than cosmetic purposes, this could be very significant. Unfortunately, this also appears to be the situation with the highest chance of adverse effects. The people documented to be most at risk have been children with cerebral palsy and other patients who use the toxin for deep muscle applications at the extremities, rather than for head and face issues. Some patients with cervical dystonia or vocal dysphonia also experience problems with swallowing after treatment. This can be dangerous, because it allows the aspiration of material into the lungs that can lead to life-threatening infection. Where does all this leave the massage therapist in the spa and the other one in the clinic? The spa therapist has guidelines that are fairly clear: no facial massage on the day of injections, and no prone work either—any massage must be conducted without putting pressure on the face. That client can receive massage as usual when the full effect of the Botox treatment is achieved, which may take several days. For the clinical therapist, the guidelines are murkier. Questions that need to be answered include: Where was the injection, and what condition was it for? How recent was the treatment? Should she work deeply on the injection sites to help the toxin be more effective? Should she avoid the area to reduce the risk of an adverse reaction? What kinds of adverse reactions are possible? In this situation, we are in largely uncharted territory, but we are not here alone. With the client's permission, it is possible to work closely with the neurologist or other specialist who administers the injections and to follow up with the client to track results. Therapy Foundation. She is a writer and NCBTMB-approved provider of continuing education. She wrote A Massage Therapist's Guide to Pathology (Lippincott Williams & Wilkins, 2009), now in its fourth edition, which is used in massage schools worldwide. Her latest book, Disease Handbook for Massage Therapists (Lippincott Williams & Wilkins, 2009), is also available at www.lww.com. Werner can be reached at www.rutherwerner. com or wernerworkshops@ruthwerner.com. Ruth Werner is president of the Massage Author's note: several people shared their Botox stories with me to assist with this piece, and for them I am immensely grateful. We all benefit from such generosity. My thanks to you all. earn CE hours at your convenience: abmp's online education center, www.abmp.com 105