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
- 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
- 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
- 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.
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.