Learn How Massage Therapy Could Help Congestive Heart Failure

Over the past number of years, we’ve looked at many different medical emergencies you may have to deal with in your massage therapy practice. 

We’ve covered strokes, heart attacks, anaphylaxis, diabetic reactions, and so much more, even to the point of looking at how massage can help hypertension. 

However, after a discussion on Facebook this week around hypertension and circulation, Congestive Heart Failure came up. 

I don’t treat anyone who deals with this, but as you know, I’ve been a first responder for many years and have responded to many heart-related issues, so I figured this might be a good topic to tackle. 

As always, we’ll look into the physiology and the emergency side of things, but we’ll also dig into what we can do as Massage Therapists to help this population out. 

What Is Congestive Heart Failure?

While CHF (congestive heart failure) is a heart issue, it’s not the same as a heart attack. 

It’s a gradual failure or weakness of one side of the heart, or sometimes both sides.(1)

As you’ll recall from college (yes, I realize it was a long time ago), the left side of the heart pumps oxygenated blood to the body, while the right side receives deoxygenated blood from venous return and pumps it to the lungs.

There can be a few risk factors leading up to someone suffering from CHF, which include: 

  • Myocardial Infarction
  • Valvular Disease
  • Ischemic Heart Disease
  • Or a disease that affects the myocardium of the heart. (1)

As mentioned earlier, we’ve written blogs on hypertension before (and how we can help), but hypertension is also one of those risk factors which could lead to CHF. One paper demonstrated this to be one of the most common risk factors associated with CHF and contributed to a large volume of heart failures.(2)

This is one reason why it may be essential for you to check a patient’s blood pressure on at least a semi-regular basis.

Due to hypertension, the left ventricle is continually trying to pump against restricted peripheral arteries. The left side is also the side that takes the brunt of damage due to myocardial infarction. So, both injuries result in the heart not being able to pump blood effectively, so the blood coming in from the lungs backs up, causing pulmonary edema. (1) 

The signs and symptoms we might see with this are(1):

  • Breathing issues:
    • shortness of breath
    • faster respirations
    • shortness of breath when lying down, which gets better when standing
    • wheezing
    • coughing up blood-tinged sputum
  • Circulatory issues: 
    • increased heart rate
    • cyanosis (bluing of the lips) 
    • pale, cool, clammy skin (signs of shock)
    • normal to high blood pressure
    • confusion and disorientation (also signs of shock)

When right-sided failure occurs, it’s usually due to issues on the left side when pressure is transferred back to the lungs because of the backed-up congestion.

However, it can also be due to: 

  • pulmonary embolism
  • COPD
  • myocardial infarction

We would see that right-sided failure looks a little different because blood is getting backed up in the person’s veins. Those signs and symptoms look more like: 

  • shortness of breath
  • fainting
  • weakness along with fatigue
  • swelling of lower limbs and lower back (how many people per week do you treat with low back pain?).
  • jugular venous distension (JVD, is easiest to see in semi-fowlers or supine)
  • tachycardia or a cardiac arrhythmia 

One of the big reasons it’s essential to know all of this is that there may be things we can do to help the patient and because their safety should be our number one priority. 

When anyone is coming in for treatment, we must be cognisant of underlying issues that could lead to a medical emergency. Of course, you know I have to bring this up…these issues could lead to us having to perform CPR. If you haven’t taken a course in a while, you owe it to your patients and your loved ones to keep up to date, as it could save a life one day. 

Now that we know the signs and symptoms and the importance of checking blood pressures on a regular basis; let’s look at what effect we can have in helping this population.

What Can Massage Therapy Do?

A little tough to find a lot of research on how massage can help this (well, honestly, there’s not a lot of good research on massage out there); however, I found a few that had similar findings. 

In both studies,(3)(4) the patients were going through admission to the hospital’s cardiac ward. They began massage three days after, so it did not interfere with any medical intakes or procedures; the patients were asked to sit up and position themselves at a bedside table with a pillow. 

In each study, they showed how respiratory rate and blood pressure both decreased, and blood oxygen saturation improved. 

Interestingly one of the studies(4) demonstrated that massage helped decrease patients’ anxiety with a significant difference between men and women, with men having the more significant outcome in this regard. 

One thing I had a hard time with is both studies said: “Back massage can also improve pulmonary function and promote circulation when the amount of blood in the pulmonary artery increases. The increased amount of blood has more opportunity to exchange gases, enabling more oxygen supply throughout the body and raising the oxygen saturation level.”

While it’s true if more blood could get to the lungs, more gas exchange would happen, how is this possible with decreased respiration, HR, and decreased BP? Both studies were conducted without a control group to compare, so I have to question some of the outcomes.

I have no doubt the decrease in respiration, heart rate, and anxiety occurred because we know massage has positive effects at decreasing the SNS firing and has positive benefits for mood and depression. 

However, I have to question the “promoted circulation part.” The only explanation that would make sense to me is if decreasing respiration, heart rate, and BP makes it easier for the heart to pump; I supposed this could make for “promoting” circulation, but not sure we could say “increased.” 

Another study (5) looked at how massage could help with sleep patterns, and the results showed that patients both got to sleep faster and slept longer on average. This is another valid point as we have seen many other studies showing the benefit of massage for sleep. Sleep apnea (6) is also quite common in those with CHF, so if we can help with sleep in any way (they would need a CPAP machine to make a difference with the apnea), that’s a positive too. 

What I had a hard time finding was anything regarding patient positioning on the table. However, there was mention that standing was better than sitting, and the ability to use gravity to help in different ways would be beneficial. So, if you have patients with right-sided failure, and in turn swelling in the lower limbs having them on the table with legs elevated would presumably help with the swelling. But I also think you’d want to limit the time spent in that position, so you aren’t overloading the heart with increased venous return (I’d love to see some actual stats on this to see if duration mattered). Due to the possible breathing issues, the semi-fowlers position is probably more advantageous than lying prone, but if there aren’t breathing issues, then prone is perhaps okay for a bit. 

When we look at the clinical guidelines(7) on heart failure treatment, the recommendations are for exercise. This makes complete sense to me as there is also a correlation between diabetes (8) and CHF. As well when we looked at the studies on massage and CHF, part of the improvements was on improved anxiety, and we know exercise can help both anxiety and diabetes. Exercise would also play a large role in the improvement in circulation, venous return, and respiration. So, while someone may be coming in hoping we can help them (which we can), the better approach would be to use massage in conjunction with a good exercise plan. If you’re not comfortable designing an exercise plan, why not include a fifteen-minute walk with your patient, then some treatment, or vice-versa? Or reach out to someone you trust with exercise prescription and work together with them on a treatment plan? Either way ensure that no matter what, the patient’s safety comes first, which also means being prepared for a medical emergency if their condition worsens while they’re in your care. 

References

1. The Canadian red cross society. EMERGENCY CARE for Professional Responders. ; 2018.

2. Braunwald E, Bristow MR. Congestive heart failure: fifty years of progress. Circulation. 2000 Nov 14;102(suppl_4):Iv-14.

3. Jamali S, Ramezanli S, Jahromi MK, Zare A, Poorgholami F. Effect of massage therapy on physiologic responses in patients with congestive heart failure. Biosciences Biotechnology Research Asia. 2016 Mar 31;13(1):383-8.

4. Chen WL, Liu GJ, Yeh SH, Chiang MC, Fu MY, Hsieh YK. Effect of back massage intervention on anxiety, comfort, and physiologic responses in patients with congestive heart failure. The Journal of Alternative and Complementary Medicine. 2013 May 1;19(5):464-70.

5. Sable A, Sivabalan T, Shetti AN. Effectiveness of back massage on sleep pattern among patients with congestive cardiac failure. Iranian journal of nursing and midwifery research. 2017 Sep;22(5):359.

6. Sharma B, Owens R, Malhotra A. Sleep in congestive heart failure. Medical Clinics. 2010 May 1;94(3):447-64.

7. Shoemaker MJ, Dias KJ, Lefebvre KM, Heick JD, Collins SM. Physical therapist clinical practice guideline for the management of individuals with heart failure. Physical therapy. 2020 Jan 23;100(1):14-43.

8. Kannel WB, Hjortland M, Castelli WP. Role of diabetes in congestive heart failure: the Framingham study. The American journal of cardiology. 1974 Jul 1;34(1):29-34.

Managing A Collapse In Your Massage Therapy Clinic

Like it or not, it is going to happen one day.

You do your intake with a patient, leave the room and on your return there they are, lying on the floor not breathing.

Your adrenaline rushes because you never thought you’d actually have to deal with this…ever.

But the odds are against you.

According to the heart rhythm society, in the U.S. more than 350,000 deaths occur each year because of sudden cardiac arrest, which is more than breast cancer, lung cancer or AIDS.

Sudden cardiac arrest takes an average of one life every two minutes.

Unfortunately 95% of people who suffer a cardiac arrest lose their life because of delayed treatment.

However the bright side is that you can help. The odds of being able to revive someone greatly increases when you witness the collapse.

Fortunately when we have our patients in the clinic, chances are we are going to witness the collapse in case they experience a cardiac arrest.

Initial CPR

If you ever witness a collapse, or walk back into your massage treatment room and see someone unconscious, the first thing you have to do is assess if the person is breathing.

We do this by using a technique called: “look, listen and feel”.

Firstly, squeeze the persons traps and see if they respond in anyway. Then put your ear overtop the persons mouth, place a hand on their chest and look at the chest for 15 seconds.

See if you can feel a breath on your ear and watch to see if your hand on the chest rises at all to indicate breathing.

If there is no air exchange occurring, tilt the persons head back, check to see if they start breathing. If they don’t start breathing on their own keep the head tilted back and attempt to give the person two breaths.

Watch to see if the chest rises, indicating air going into the lungs.

If the chest rises, it shows that the person has an open airway, so you can begin chest compressions (if the air didn’t go in, it means something is blocking the airway so they could have choked on something).

If they had choked on something, you would start compressions as well, however the intent of the compressions now is to clear whatever the person had choked on.

To start your compressions, landmark at the persons armpit on the side of the body opposite to you. Then bring the palm of your hand up to the sternum and deliver 30 chest compressions.

Continue to deliver 30 compressions and two breaths until more help arrives.

Once you realized the person was not breathing and CPR was necessary it is important to get someone to call 911 for you, and if available get an A.E.D. (automated external defibrillator).

If you’re on your own, grab a phone, bring it back to the person and call 911. Put it on speaker phone and the 911 dispatchers will coach you on what to do.

Using An AED

People often think that an AED works like the paddles the doctors on TV shows like ER use to jumpstart a persons heart.

It doesn’t work like that.

If the heart is completely stopped and flat lined, the AED isn’t going to do anything.

There has to be a “shockable” rhythm, a tachycardia (fast rhythym) or bradycardia (slow rhythym) for the AED to do anything.

There are a few things to take into consideration when using an AED.

If you are in a wet environment (you sports therapists) you have to do a splash test.

If the ground is wet and you slap it, if it makes a splash you have to move the person before you can allow the AED to deliver a shock. If the ground is just wet and there is no splash, it’s fine to deliver the shock.

If the person has a really hairy chest, then you have to shave the chest before putting the pads on. The pads have to be in direct contact with the skin to work properly (fortunately AED kits come with a razor in them).

Also if there is any metal (ie: underwire bra, jewelery etc.) in the path of the pads, it should be removed or it will leave burn marks. Same for any kind of nicotine or medical patches, they should come off.

Then just turn the machine on and follow the directions, don’t try and jump ahead, just do what it tells you.

Make sure when the machine says “everyone stand clear”, no one is touching the patient. If someone was still doing compressions, the machine would read that as the rhythm of the heart instead of it’s actual rhythm.

Also, the second time it advises to make sure “everyone stand clear”, is when it’s about to deliver a shock. Make sure no one is touching the patient or they will get shocked as well.

If the AED detects a “shockable” rhythm it will deliver a shock and you will see the body rise up a bit.

If there is not a “shockable”rhythm it will say: “no shock advised, continue doing two minutes of CPR”.

If you have a second person with you, have them take over doing CPR, so you get a break. Then alternate with the other person every two minutes so that one person doesn’t get tired out.

It should look something like this:


This can be a pretty scary situation to have to deal with. I honestly hope you never have to. However if this ever happens and the outcome isn’t what you had hoped for, please reach out and talk to someone about it. As healthcare professionals we are constantly telling patients to do proper home care, or are referring people to get more help should they need it. This is one of those cases where we really have to take care of ourselves after an incident like this. Chances are if this happens in your clinic, you already have a therapeutic relationship (and possibly a long standing one) with your patient. Going through a shocking scenario (no pun intended) such as this can bring up some very strong and sometimes scary emotions from the person who has to perform CPR. So please reach out and get some counselling or talk to some sort of mental health professional should you ever go through this. Remember how important your own self care is.

 

 

Choking Emergencies And Infant Massage

 

More and more I’m seeing Massage Therapists offering infant massage as well as massage classes for parents to teach them how to connect with baby and give that extra bit of care to their new infant.

But what happens when there is a medical emergency with an infant in your clinic?

Do you know what to do when one of those infants starts choking?

To start, play the first video below and I’ll get into some instructions on how to handle this kind of emergency in your clinic.

It’s a valuable skill to have and is important in and out of your clinic. But keep in mind, the videos are not a substitute for taking a proper course.

So remember, if the baby is coughing that means they have an open airway it is just somewhat restricted.

We don’t do anything except encourage them to cough up whatever it is they are choking on.

You need to intervene if:

  • The baby is making high pitched noises.
  • Is too weak to cough.
  • Is wheezing.
  • Becomes rigid due to a completely restricted airway.

Have someone call 911, get an AED (if available) and start your back blows and compressions.

Make sure the baby is always supported on your thigh, so there is a solid surface to deliver your back blows and compressions against. With the baby sandwiched between your forearms deliver five back blows between the shoulder blades.

Then flip baby over and rest on your other thigh, deliver five chest compressions with two fingers land marking between the nipples. You want to deliver about a 1.5 inch compression.

Continue to do this until the object is cleared and baby starts to cry, or becomes unconscious.

If the back blows and compressions didn’t clear the airway, now you’re doing CPR.

However once the baby went unconscious there is a chance the airway opened up because of the musculature in the neck relaxing, so we “look listen and feel” for 15 seconds to see if baby has started to breathe at all.

If they’re still not breathing, we slightly tilt the head back to try and open the airway and attempt to give two breaths. If there is still a blockage and we see that no air went in with the breaths, (if air does go in and baby is still unconscious and not breathing, we still continue) we landmark between the nipples and deliver 30 chest compressions using two fingers.

We continue with 30 compressions and two breaths until the baby starts breathing on its own, or more help arrives to take over CPR.

When First Responders arrive, they will take over CPR but have some equipment and different techniques they will use to help the baby.

Hopefully if you are doing infant massage, or just know someone who has a baby, these videos will help you feel a little more confident should you ever have to deal with a choking emergency. Please remember that these videos and this blog should not be used as a replacement for taking an actual CPR course. If this is something you do a lot in your practice, please take the time to go and get the necessary training to be confident in dealing with infant emergencies, it could literally mean someones life one day. If you know someone or have a colleague that could benefit from the information here please share it with them.