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PATHOLOGY PERSPECTIVES patients, although the arthritis is not usually erosive. Excessive scar tissue may bind up peripheral nerves, leading to entrapment symptoms. Finally, the kidneys may become a target of the infl ammatory onslaught, leading to the accumulation of scar tissue and loss of function. About half of the deaths directly due to scleroderma are related to renal failure. TREATMENT FOR SCLERODERMA Because this disease takes a unique path and time line with each patient, no universally applicable treatment protocol for scleroderma has been developed. The highest priority is to manage the symptoms and complications so that they create a minimum of destructive tissue changes. These strategies can include drugs to manage acid refl ux and improve digestive motility; lotions and physical MASSAGE? A client with scleroderma who has developed any of the organ-related complications discussed above, especially involving heart, lung, or kidney function, will require adjustments in treatment approaches to stay within the client's ability to adapt to the changes massage requires. Interestingly, a few small-scale research studies have included massage as a treatment option for scleroderma patients. One of them studied acupressure to indirectly affect esophageal dysfunction. The fi nding was that it is possible to change esophageal mobility with this intervention.2 Another study asked if skin mobilization massage, along with exercise and other therapies, was better for longtime function than home-based exercise alone. Not surprisingly, it was.3 And fi nally, one study followed what kinds of CAM Because the quality of the skin is often affected, a therapist might have to make significant adjustments to a treatment protocol. therapy to keep skin as stretchy as possible; and careful and thorough maintenance of tooth, heart, lung, and kidney health. Some of the disease- modifying immune system drugs that are highly successful for treating other autoimmune diseases are used in this context, but managing complications appears to take precedence. therapies scleroderma patients pursued in addition to their conventional medical care. Massage therapy was a popular choice, and the authors postulated that stress management was a leading incentive in that pursuit.4 No fi rm guidelines for massage and scleroderma have been developed, but some variables clearly provide boundaries for modality choices. Because the quality of the skin is often affected, a therapist might have to make signifi cant adjustments to a treatment protocol. These might include special focus on improving mobility, avoiding ulcerations, or respecting the fragility of atrophied areas. Because scleroderma is a potentially serious disease that is not well understood, any massage therapist who has a client with this condition would do well to communicate with the rest of the health-care team to get the best guidance about possible risks and benefi ts of bodywork. This is an occasion to blaze a trail: I hope anyone with this opportunity would carefully document the experience and share it with the rest of us. noTES 1. "Limited scleroderma (CREST syndrome)," Mayo Foundation for Medical Education and Research (MFMER). Available at mayoclinic.com/health/ crest-syndrome/ds00580 (accessed October 2009). 2. D. Wollaston et al., "Patients with Systemic Sclerosis Have Persistent Alterations in Gastric Myoelectrical Activity with Acupressure to Neiguan Point PC6," The Journal of Rheumatology 32, no. 3 (2005). 3. S.M. Bongi et al., "Effi cacy of Connective Tissue Massage and Mc Mennell Joint Manipulation in the Rehabilitative Treatment of the Hands in Systemic Sclerosis," Clinical Rheumatology 28, no. 10 (October 2009): 1167–73. 4. K. Hui et al., "Scleroderma, Stress and CAM Utilization," Evidence-Based Complementary and Alternative Medicine, 2007. Available at http://ecam.oxfordjournals.org/cgi/content/short/ nem142v1?rss=1 (accessed October 2009). 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 new book, Disease Handbook for Massage Therapists, is now available from Lippincott Williams & Wilkins. Werner can be reached at www.ruthwerner.com or wernerworkshops@ruthwerner.com. Ruth Werner is a writer and NCBTMB- connect with your colleagues on massageprofessionals.com 111