Strokes in Broad Strokes

Two People, Two Strokes, Two Outcomes

“Mrs. Flores,” age 68, had a minor stroke three years ago, related to atrial fibrillation. She had a cardiac ablation to fix this problem and did physical and occupational therapy to regain full function in her left arm and shoulder. Now she takes an anticoagulant, along with blood pressure management drugs. Although her left arm is a little weaker now, she is physically more active than she used to be; she retired from her sedentary job and spends many hours each week working at the community garden and teaching at an after-school literacy program. She hurt her back while pruning a fruit tree and hopes that massage will help her pain.

“Mr. Johnson,” 77, had a severe stroke two years ago. He lost most of the use of his left arm and hand and was unable to speak clearly for several months afterward. After extensive physical, speech, and occupational therapy, he can speak a bit and walk slowly with a walker. However, he has severe chronic pain, and his right arm is weak and contracted with limited range of motion. He had pneumonia twice in two years and has lost some cognition. He can no longer live independently and has moved into an assisted-living facility. His son would like 
for Mr. Johnson to receive seated massage for general comfort and wellness.

I invite you to keep Mrs. Flores and Mr. Johnson in mind as you read this article. We will revisit them in the discussion of where massage therapy fits for clients with a history of strokes.

What Is a Stroke?

Here’s a fun fact: Your brain comprises just 2 percent of your body mass, but it is your most metabolically active organ, consuming between 15–20 percent of your glucose and oxygen intake while you are at rest.¹ The consequence of the brain being so busy is that if something interrupts blood flow, like debris or an intracerebral bleed, then brain cells die fast; almost 2 million cells are lost with each minute of oxygen deprivation.² This is what happens in a stroke. An antiquated term for stroke is apoplexy, from the Greek apoplexia, which means “to strike down by violence.”

As a pathology writer and educator, I like to put a positive spin on the discussion of diseases and conditions whenever I can. I want to focus on the miraculous process of healing, because our work often creates opportunities and support for that to happen. Today’s topic can feel very sobering, especially when we consider stroke statistics. But even here, our work may be useful, if it is carefully and skillfully applied.

While you are reading this sentence, someone in the US is having a stroke. By the time you reach the end of this article, there will probably have been 10 or 12 more strokes (one every 40 seconds), and three or four deaths related to stroke (one every 3 minutes and 11 seconds).³ Strokes are a leading cause of disability for elders and the reason many people move from independence into assisted-living facilities.⁴

About 795,000 strokes occur in this country every year.⁵ It is the fourth or fifth leading cause of death in the US (depending on the source), leading to about 140,000 deaths per year; that means about 17 percent of people who have a stroke die as a result of that event. While most strokes happen in older people, about 10 percent occur in people between 18 and 50 years old.⁶

Stroke, however, is not an equal-opportunity threat. The risk of a first stroke is twice as high for Black adults as it is for non-Hispanic Whites; and Blacks, Native Americans, and Pacific Islanders have the highest death rates associated with strokes. Many more racial and ethnic disparities exist, which can be connected to problems with access to early treatment, plus risks related to undertreated hypertension and diabetes, along with inequities in emergency care.⁷

Today’s stroke mortality rate is lower than previous years, and substantially lower than 20 years ago: a bright spot in these statistics.⁸ Another positive is that more people with a history of stroke are alive today than ever—between 7 million and 9 million of them, which is just over 3 percent of the US adult population.⁹ That means the chances massage therapists may have stroke survivors as clients are strong, especially because massage therapy is a popular intervention for this group. The flip side of that benefit is it is very possible that inexpertly applied touch can contribute to the risk of—or even cause—a stroke.

For both these reasons, positive and negative, it is important for massage therapists to be familiar with this condition, the benefits we may bring to these clients, and the risks our work may pose.

Types of Stroke

We have already defined strokes as events in which brain cells die because of lack of blood supply. There are two main types of strokes:

• Ischemic—Those related to blockages and ischemia (usually with a traveling or stationary blood clot or bit of debris)

• Hemorrhagic—Those related to intracerebral bleeds, when an artery inside the brain ruptures

Ischemic and hemorrhagic strokes both interrupt blood flow to downstream cells. Each stroke type has subtypes, and it can be useful to identify which is which. Refer to the Types of Strokes chart to see how they are labeled.

Stroke specialists add more subcategories, but this chart is sufficient for our discussion. It is also possible to have a stroke that affects the spinal cord rather than the brain, but that is a much rarer event, accounting for less than 1 percent of all strokes.¹⁰

Ischemic Strokes

Ischemic strokes are by far the most common type of strokes in the US, accounting for about 87 percent of all cases.¹¹ Under this heading, we find two subtypes: cerebral embolism, which involves blockages that travel to the brain from elsewhere, and cerebral thromboses, which involve blockages that form inside the arteries of the brain.

Cerebral emboli usually arise from blood clots that form inside the heart, especially in the context of atrial fibrillation, or from the carotid artery, which is often the site of atherosclerotic plaques that may fragment and travel. Transient ischemic attacks (TIAs), also called ministrokes, are small-scale ischemic strokes that may involve only temporary symptoms. By contrast, thromboses originate and then grow inside the cerebral arteries until they finally obstruct blood flow to all the downstream cells.

Hemorrhagic Strokes

Hemorrhagic or bleeding strokes often arise from cerebral aneurysms: weak spots in the arteries where the vessels bulge. If that weak spot ruptures, it causes a hemorrhagic stroke. These are typically discussed as two types, based on their location. Bleeds within the brain are intracerebral strokes, and they can cause direct damage to brain cells. Bleeds on the surface of the brain are subdural strokes. They mainly cause indirect damage by increasing pressure inside the skull, which can damage nerve tissue and cause secondary inflammation. Hemorrhagic strokes are much less common than ischemic strokes, accounting for about 13 percent of all events, but they are associated with a higher risk of permanent disability and death.¹²

What Happens to Brain Tissue with a Stroke?

When brain cells are deprived of oxygen, a cascade of chemical reactions leads to cell death. But this core of dead tissue, the infarction, is only one part of the damage that strokes can cause. During a stroke, ischemia can affect cells in the areas that surround the infarction, because edema and inflammation also limit oxygen supply to the surrounding area. The cells in this “ischemic penumbra” can survive for longer than the completely oxygen-deprived cells, but only for a few hours.

In addition, the death of protective glial cells and vascular tissue leads to a breakdown of the blood-brain barrier and general cerebral edema that can cause seizures and other complications. This is why it is so important to get immediate care for a stroke—every minute of delay threatens the death of more tissue.

Risk Factors for Stroke

The factors that increase the risk of having a stroke are mostly controllable, if people have access to preventive health care and good air quality. The biggest factors include uncontrolled high blood pressure, obesity, uncontrolled diabetes and cholesterol, and kidney problems. Using tobacco (including smokeless tobacco products), having exposure to secondhand smoke, a sedentary lifestyle, and an unhealthy diet are other important contributors.

Some stroke risk factors are less controllable. Sleep disorders are an important contributor; severe obstructive sleep apnea substantially increases stroke risk. Atrial fibrillation is another contributor, as is long-term exposure to air pollution. When these are combined with issues like diabetes, kidney failure, or previous stroke, then the risks increase dramatically.

Fortunately, research also shows that controlling whatever risk factors can be controlled has a direct positive impact on stroke risk.¹³ This speaks to the importance of health-care access, early awareness, 
and self-care.

Signs, Symptoms, and Consequences of Stroke

We won’t go into detail about the signs and symptoms of someone having a stroke, because that is more relevant to a first-aid class than to a massage therapy practice. However, knowledge of the BE-FAST mnemonic is an easy way to identify when a person needs emergency medical care for a possible stroke.¹⁴

BE-FAST stands for:

• Balance: sudden loss of balance or coordination

• Eyesight: vision changes, loss of vision in one or both eyes

• Face: one side of the face is weak or drooping

• Arms: one arm is much weaker than the other

• Speech: speech becomes slurred, confused, or incoherent

• Time: time to get help—every minute of delay means more brain damage

The person may also have dizziness, nausea, asymmetrical pupil dilation, a sudden onset of a severe “thunderclap” headache, and decrease or loss of consciousness. Any combination of these symptoms is reason to call emergency services right away. The most important thing to remember in this situation is that “time is brain,” and people who receive care quickly have a better prognosis than those who receive delayed care.¹⁵

Post-stroke complications are much more relevant to massage therapy practice, since they may have long-term impact on health. Weakness, numbness, paralysis, and progressive loss of function in the limbs of the affected side are common. Some of this is directly related to central nervous system (CNS) damage, but some of it may be reinforced by reflexes initiated in the peripheral nervous system. People who have had a stroke may lose some vision. Mental changes might include memory loss, personality changes, and depression and anxiety—which often make other symptoms worse and more resistant to treatment. About 1 percent of patients develop seizures that may or may not resolve.

People who have had a stroke often have swallowing and eating problems, which puts them at risk for aspiration pneumonia. And an underaddressed consequence of stroke is severe chronic pain that can become self-sustaining and extremely difficult to resolve.

Massage Therapy for Strokes

With 7–9 million stroke survivors in this country, the chances are excellent that you have encountered or will encounter clients who have experienced this challenge. And, as we saw with Mrs. Flores and Mr. Johnson, no two clients are alike.

Guidelines for safe and effective bodywork with this population depend on many variables. Here are a few questions for the client or the client’s caretaker to help establish some ideas about safe choices:

• What would you like to accomplish with your massage today?

• How long ago was your stroke?

• What kind of stroke was it?

• Do you know what your risk is for having another one?

• What has changed for you since your stroke?

• What medications do you take, and what are their side effects?

• Is it safe for you to exercise? Tell me about your exercise.

• Describe your activities on an average day.

• What would you like to be able to do that massage therapy can help with?

These questions can help determine a person’s overall resilience and capacity to adapt to various types of bodywork. If we ask these questions of Mr. Johnson and Mrs. Flores, even though they both had ischemic strokes, the answers will reveal that guidelines for safe bodywork for these two clients are substantially different.

People like Mrs. Flores may be able to return to full function with only minimal lingering problems. However, it is important to know what medications they take, since blood thinners are likely to be among them, and those carry a risk of easy bruising. Other side effects might include fatigue or dizziness when standing, so that is an important question. In Mrs. Flores’s case, massage to help with her back pain from overdoing it in the garden will probably not require other major adaptations related to her stroke history.

As many as 9 million people in the US have survived a stroke, and they may be looking for massage therapy.

However, people whose strokes were more severe may require a lot of accommodation. Mr. Johnson, in addition to being physically frail, has communication difficulties and a recent history of infections and other challenges. Coordinating careful massage with his health-care team will be important to help him receive the benefits of reduced pain and anxiety without creating additional risks. For him, gentle shoulder, arm, and hand massage as he sits in a comfortable chair, in a setting where he feels safe and secure, may help him feel less stressed, better oriented, and capable of freer movement.

He is likely to have some tightness or even contractures in his affected limbs, and work in these areas may also help alleviate pain and improve his range of motion. If he and his team agree, then work on his feet and lower legs may also help with his gait, balance, and steadiness, since these are significant factors that put people at risk of falling.

What Does the Research Say?

Research demonstrates several benefits for people who have had strokes, and it is helpful to have this foundational evidence on which to base some decisions.

Safety

All the studies about massage and stroke I could find reported no adverse effects for patients undergoing medical care who received massage from appropriately educated practitioners. This is an important consideration, because an absence of adverse events while subjects enjoy the benefits of massage therapy is supportive of our practice.

Timing

A comparison of early and delayed rehabilitation treatment for hemiplegia related to stroke found better results with early treatment, which suggests that massage therapy could be more effectively integrated into early stroke recovery practices.¹⁶

Spasticity and Motor Function

A large systematic review and meta-analysis found that manual therapy, especially tui na, in combination with conventional physical therapy, led to improved motor function and reduced spasticity among people who had experienced a stroke.¹⁷ The authors of this paper also expressed surprise at the scarcity of published articles regarding Swedish or relaxation massage for this population—a current hole in the data.

Balance and Gait

A few large and small studies have found that various types of massage therapy can improve balance and gait, which may reduce the risk of falls, an important consideration for stroke patients.¹⁸

Risks

All that said, massage therapy carries some specific hazards, especially for people who are at risk for stroke. And given that stroke is closely linked to heart disease, and that heart disease is the leading cause of death in the US, the truth is that many of our older clients may be at risk for having a stroke.

Massage, usually at the hands of untrained people or via machines, has been identified as a factor in several case reports about adverse effects. Sometimes these cases only make it into litigation, so details are withheld from the public, but some of them become published papers. These almost always involve intrusive manipulation of the neck, where blood vessels are vulnerable to being damaged.¹⁹ The takeaway here is that to work safely in this area, massage therapists must be extremely well educated about the anatomy of the neck, local endangerment sites, and stroke risk.

Closing Thoughts

The benefits of welcomed, educated touch for people who have had a stroke cannot be summed up in a few lines.

While improvements in pain, range of motion, balance, and strength may be important clinical goals, our work can provide whole other worlds of benefits, starting with the difference between being handled and being touched. People who have a health crisis that involves a hospital stay and/or a long and difficult recovery get lots of handling from people who mean well, but who are primarily task-oriented. Many patients appreciate simple touch: not necessarily related to a chore, but just because it feels good.

Many people with “chronic stroke”—which refers to a long, slow recovery period—find that the spasticity in their extremities, especially in their affected hands, arms, and shoulders, gets worse over time. This may be a consequence of proprioceptive responses to nerve damage in the brain: the flexor muscles tighten because of signals from the CNS, and the peripheral proprioceptors reinforce a new and limited movement pattern. The result is cumulative loss of function and range of motion. The good news is that some of that progressive tightening of the flexors may be treatable with careful massage. I also explore the topic of spasticity and the role massage therapy plays in that context in my column “Too Much Tone: Massage Therapy and Spasticity” in the November/December 2024 issue of Massage & Bodywork.

It’s hard to overstate the value of bodywork that helps people have less pain, feel more confident about their movement, be steadier on their feet, and be able to walk more independently. Our ability to help with gait and balance can have a substantial impact on people in their stroke recovery.

It is almost inevitable that surviving a stroke will have an impact on a person’s mental state. Having a stroke is a life-changing event that affects physical and mental capacity. The relationship between stroke and depression is circular: People who have depression have a higher risk of stroke.²⁰ And people who have had a stroke and develop depression have a poorer prognosis than others.²¹ We know massage therapy doesn’t “cure” depression, but it can help improve many aspects of this mood disorder by reducing anxiety and sleeplessness and improving self-esteem and self-efficacy. For more on the experiences of massage therapists who work with clients who have had a stroke, please see the video that accompanies this article.

Up to 9 million people who have had a stroke live in this country, and they have various levels of disability. Massage therapy doesn’t undo damage that has been done, but our work can offer pain relief, improved range of motion, better function, and genuine human connection to people who need us. Isn’t it great to be part of a profession that can help make their lives better?

Notes

1. CDC, “Stroke Facts,” accessed August 7, 2024, https://cdc.gov/stroke/data-research/facts-stats/index.html.

2. Stroke Awareness Foundation, “Stroke Facts & Statistics,” accessed August 9, 2024, https://strokeinfo.org/stroke-facts-statistics.

3. Seth S. Martin et al., “2024 Heart Disease and Stroke Statistics: A Report of US and Global Data from the American Heart Association,” Circulation 149, no. 8 (February 2024): e347–913, https://doi.org/10.1161/CIR.0000000000001209.

4. Paying for Senior Care, “Stroke Care and Assisted Living,” accessed August 13, 2024, https://payingforseniorcare.com/stroke-care-and-assisted-living.

5. Stroke Awareness Foundation, “Stroke Facts & Statistics.”

6. CDC, “Stroke Facts.”

7. National Institutes of Health, “Racial Disparities in Stroke Incidence and Death,” accessed August 16, 2024, https://nih.gov/news-events/nih-research-matters/racial-disparities-stroke-incidence-death. 

8. Ann Pietrangelo, Healthline, “The Top 10 Deadliest Diseases in the World,” accessed August 9, 2024, https://healthline.com/health/top-10-deadliest-diseases.

9. Martin et al., “2024 Heart Disease and Stroke Statistics: A Report of US and Global Data from the American Heart Association.”

10. Fredrik Romi and Halvor Naess, “Spinal Cord Infarction in Clinical Neurology: A Review of Characteristics and Long-Term Prognosis in Comparison to Cerebral Infarction,” European Neurology 76, no. 3–4 (October 2016): 95–8, https://doi.org/10.1159/000446700.

11. Martin et al., “2024 Heart Disease and Stroke Statistics: A Report of US and Global Data from the American Heart Association.”

12. Martin et al., “2024 Heart Disease and Stroke Statistics: A Report of US and Global Data from the American Heart Association.”

13. Martin et al., “2024 Heart Disease and Stroke Statistics: A Report of US and Global Data from the American Heart Association.”

14. Sushanth Aroor, Rajpreet Singh, and Larry B. Goldstein, “BE-FAST (Balance, Eyes, Face, Arm, Speech, Time),” Stroke 48, no. 2 (February 2017): 479–81, https://doi.org/10.1161/STROKEAHA.116.015169.

15. CDC, “Stroke Facts.”

16. Manuela Morreale et al., “Early Versus Delayed Rehabilitation Treatment in Hemiplegic Patients with Ischemic Stroke: Proprioceptive or Cognitive Approach?” European Journal of Physical and Rehabilitation Medicine 52, no. 1 (February 2016): 81–9, https://pubmed.ncbi.nlm.nih.gov/26220327.

17. Rosa Cabanas-Valdés et al., “The Effectiveness of Massage Therapy for Improving Sequelae in Post-Stroke Survivors. A Systematic Review and Meta-Analysis,” International Journal of Environmental Research and Public Health 18, no. 9 (April 2021): 4424, https://doi.org/10.3390/ijerph18094424.

18. Kyun-Hee Cho and Shin-Jun Park, “Effects of Joint Mobilization and Stretching on the Range of Motion for Ankle Joint and Spatiotemporal Gait Variables in Stroke Patients,” Journal of Stroke and Cerebrovascular Diseases 29, no. 8 (August 2020): 104933, https://doi.org/10.1016/j.jstrokecerebrovasdis.2020.104933; JoEllen M. Sefton, Ceren Yarar, and Jack W. Berry, “Massage Therapy Produces Short-Term Improvements in Balance, Neurological, and Cardiovascular Measures in Older Persons,” International Journal of Therapeutic Massage & Bodywork 5, no. 3 (September 2012): 16–27, https://doi.org/10.3822/ijtmb.v5i3.152; Xie Yunhui et al., “Efficacy of Meridian Massage for Motor Function After a Stroke: A Systematic Review and Meta-Analysis,” Journal of Traditional Chinese Medicine 42, no. 3 (June 2022): 321–31, https://pmc.ncbi.nlm.nih.gov/articles/PMC9924753; Phan T. Nguyen, Li-Wei Chou, and Yueh-Ling Hsieh, “Proprioceptive Neuromuscular Facilitation-Based Physical Therapy on the Improvement of Balance and Gait in Patients with Chronic Stroke: A Systematic Review and Meta-Analysis,” Life 12, no. 6 (June 2022): 882, https://doi.org/10.3390/life12060882.

19. Shakaib Qureshi, Muhammad U. Farooq, and Philip B. Gorelick, “Ischemic Stroke Secondary to Stylocarotid Variant of Eagle Syndrome,” The Neurohospitalist 9, no. 2 (April 2019): 105–8, https://doi.org/10.1177/1941874418797763; Edgar R. Lopez-Navarro et al., “Ischemic Stroke Secondary to Self-Inflicted Carotid Sinus Massage: A Case Report,” Journal of Medical Case Reports 15, no. 83 (February 2021): 83, https://doi.org/10.1186/s13256-021-02680-1; Alissara Vanichkulbodee, Suwara Issaragrisil, and Pholaphat C. Inboriboon, “Massage-Induced Spinal Epidural Hematoma Presenting with Delayed Paraplegia,” The American Journal of Emergency Medicine 37, no. 4 (April 2019): 797.e1–797.e4, https://doi.org/10.1016/j.ajem.2019.01.017.

20. Katharine Lang, “Depression May Increase Stroke Risk, Impact Stroke Recovery,” MedicalNewsToday, accessed August 13, 2024, https://medicalnewstoday.com/articles/depression-may-increase-stroke-risk-impact-stroke-recovery.

21. American Stroke Association, “Depression and Stroke,” accessed August 13, 2024, https://stroke.org/en/about-stroke/effects-of-stroke/emotional-effects/depression-and-stroke.