Issue link: https://www.massageandbodyworkdigital.com/i/72121
Unlike any of the other arthridites so far discussed, gout involves damage that begins outside the joint capsule. Uric acid, a naturally occurring byproduct of digestion, is produced in high levels when a person consumes foods that are high in purine. These foods include red meat and organ meats, some types of fish and shellfish, asparagus, cauliflower, legumes, mushrooms, and spinach. When purine-rich foods are consumed in large amounts, especially along with alcohol, uric acid can accumulate in the blood faster than the kidneys can excrete it. When uric acid concentrates, it forms microscopic needle-like crystals. These crystals are heavier than blood, and they form most readily at lower temperatures. This means they often congregate in the feet, where they collect around the joint capsule at the first metatarsal and proximal phalanx of the big toe. Acute gouty arthritis is excruciatingly painful, and when a person has had it once, he or she is vulnerable to repeat episodes, especially if the kidneys are impaired in any way that inhibits the excretion of uric acid. If one visualizes the tiny needle-like crystals corroding the joint capsule at the base of the big toe or elsewhere, it becomes self- evident that manipulating—or even moving—a joint in this acute phase of inflammation is a terrible idea. WHAT ABOUT MASSAGE? Where does all this leave the massage therapist? Short-run choices in the world of arthridites are actually easy: if a joint is hot, red, painful, and swollen, we obviously stay away. Consider inflammation a local caution and work elsewhere depending on the individual case. A person who is in a flare of RA, for instance, may also have inflammation in other tissues; this makes most types of hands-on bodywork impractical. With gout, however, the inflammation is limited to the affected area; so if the kidneys are healthy, massage elsewhere on the body is probably safe and appropriate. Osteoarthritis—the type of joint inflammation we are most likely to see—is rarely hot, red, and swollen; it is often painful, but that pain is deep and achy rather than sharp and acute. The safety of massage in this situation is fairly secure: unless we push joints beyond a comfortable range of motion, massage is unlikely to make osteoarthritis significantly worse. Whether massage can help with the pain of arthritis, however, is a different issue. When a person has joints that hurt, especially when this is a situation that persists for long periods of time, the muscles that surround the joint naturally begin to tighten in order to stabilize this weak spot. Postural and movement patterns then adapt in order to reduce short-term pain, but these patterns are often not efficient or pain-free themselves. The research on manual therapies in the context of joint inflammation is generally very supportive. A quick check of the US National Library of Medicine (www.pubmed.gov) with the search terms massage and arthritis pulls up about 130 research projects where massage was a factor in asking questions about how people can treat or address joint pain. One particularly exciting study looked at full-body Swedish massage for participants who had been diagnosed with osteoarthritis of the knee; a simple treatment regimen led to significant reductions in reports of pain compared to the control group.1 Several compelling conclusions can be drawn from this pilot study: one is that massage is a successful mechanism to reduce the pain of arthritis that does not involve taking painkillers; another is that massage in this study was not specifically directed to the knee, which means you don't have to be a knee specialist to be effective; and finally, it opens a new question about whether massage as an intervention to manage joint pain can be part of a larger strategy to delay the necessity of joint replacement surgery. The validation of massage therapy as a viable treatment option for people who are dealing with the pain of osteoarthritis is an important milestone in the development of our professional scope. It is likely that as osteoarthritis and other arthridites become an increasing public health issue, more and more interest in noninvasive and non- pharmacologic strategies will develop. It's up to us to take advantage of this opportunity by honing our skills—not only to work with this population, but to be able to form partnerships with other health-care providers by using the research that validates our work. Note 1. A. Perlman et al., "Massage Therapy for Osteoarthritis of the Knee," accessed November 2011, http://archinte.ama-assn. org/cgi/content/full/166/22/2533. Ruth Werner is a writer and educator approved by the NCTMB as a 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. Werner is available at www.ruthwerner.com or wernerworkshops@ruthwerner.com. Celebrate ABMP's 25th anniversary and you may win a refund on your membership. 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