Right now, more than 350,000 Americans experience symptoms associated with multiple sclerosis (MS), including weakness, spasm, loss of coordination, and impaired cognition. As a massage therapist, you can be sure that someone with MS will walk through your door and be desperate for help.

MS is an inflammatory disease of the central nervous system (CNS) in which the myelin sheath deteriorates, resulting in the destruction of nerve fibers. The origin is unknown, but we do know:

• There are multiple autoimmune, environmental, and genetic factors that can trigger MS.

• A person with a history of serious viral or bacterial infection is more prone to be affected.

• Usual onset is between 20 and 40 years of age.

• It occurs twice as often in young women than in young men, but after 30, both genders are equally affected.

• Every year, 25,000 new cases are diagnosed in the United States. 

Once diagnosed, MS patients typically follow a clinical course of flares and remissions. Although complete asymptomatic remission does occur, it is rare. Debilitation directly relates to the form of MS, genetic history, environmental factors, and how aggressively and consistently the disease is treated. The average life expectancy after diagnosis is 25–30 years, and complications can include minor to severe decrease in quality of life, contractures, mild to complete debilitation, secondary infections, clinical depression, and altered self-image. There is no cure.

What’s Happening in the Body?

The pathophysiology of MS is fairly straightforward. Normally, nerve signals travel at lightning speed within the CNS via fibers from the brain to the spinal cord and back again. These delicate nerve fibers are surrounded and protected by a fatty, slick coating called the myelin sheath. Innumerable signals—for gross and fine muscle movement, smell, vision, and so on—allow graceful and efficient function.

Demyelination is damage to the myelin sheath from disease or injury, after which signals do not travel smoothly. As the body attempts to repair the damaged sheath, scar tissue builds and hardens (sclerosis) in multiple spots along the myelin sheath—thus the term multiple sclerosis. Hardened, scarred patches of myelin sheath cause halting or stuttering signals from and to the brain, leading to symptoms like eye pain, muscle weakness, and spasticity.

Here’s an easy way to understand demyelination. Decades ago, household electrical cords were covered in a black, fuzzy, yarn-like material. The flow of electricity from a wall socket to a lamp was sometimes inconsistent as it ran through these fibers. Troublesome grandchildren (myself included) found it a great source of entertainment (and irritation for the grandparents) to jump up and down on these cords, causing a flickering—if not a total extinguishing—of the lamp’s light. Demyelination is similar. The normally smooth electrical conduction from the brain (wall socket) to the body (lamp) “flickers” because the smooth flow of nerve signals (electricity) has been interrupted.

The CNS has both motor and sensory nerves. This means if you pick up a hot cup of coffee, the motor nerves in your hand provide the strength and coordination to grasp and hold the cup, while the sensory nerves provide information to the brain, registering, “Aha—hot liquid.” In MS, nerve damage can result in both motor and sensory abnormalities.

Stages or Forms of MS

There is no single clinical portrait of a typical MS patient; in fact, patients are often misdiagnosed because some of their symptoms are associated with conditions such as fibromyalgia, lupus, and scleroderma. Even CNS tumors can mimic the symptoms of MS. In addition, the clinical course of the condition varies widely and is highly dependent on the initial form of MS. Patients usually linger for years or decades in the stage at which they are diagnosed before gradually progressing to a more serious form. Rarely is MS diagnosed as malignant, in which case the condition worsens rapidly and leads to an early death.

Patients with benign MS:

• Can continue to live relatively symptom-free for decades.

• Experience longer survival than with other forms of MS.

• Experience one or two early flares.

• Sometimes remain in the benign stage (15 percent of patients), but more typically progress to a more serious form of MS.

Patients with relapsing/remitting MS (the most common form):

• Experience long periods of remission, during which recovery is almost complete, interspersed with definite flares.

• Can remain in this form for life, but more often develop the next, more serious, form.

Patients with secondary progressive MS:

• Follow a similar clinical pattern as relapsing/remitting MS, but healing during remission is less successful.

Patients with primary progressive MS:

• Experience constant, low-grade flares that allow very little time to heal.

• Often steadily decline.

Patients with malignant MS (the rarest form): 

• Experience severe flares that rapidly progress into severe disability or death.

How Are MS patients Treated Medically?

After the initial diagnosis is confirmed and a baseline MRI is taken, serial MRIs (multiple scans taken at consistent intervals to track disease progression or remission) are used to determine the treatment plan and the progress of the disease. Although a holistic approach to MS incorporating gentle cardiovascular exercise, strength training, high-quality nutrition, stress reduction, and an increase in the quality and quantity of sleep is important, the primary treatment for the condition is largely pharmaceutical.

While steroids can quiet flares, drugs that limit the immune system’s response to inflammation, reduce flares, and prolong periods of remission are now most commonly used to treat MS. Interferon betas allow many patients to live almost symptom-free. These drugs, which are immunomodulators, help manage relapsing MS and reduce the development of brain lesions (injury to nerves in the brain caused by demyelination). Chemotherapeutic agents, also called antineoplastics, quiet the immune system but are reserved to treat the most severe cases of MS. Drug cocktails (combinations of two or more medications) can address a variety of symptoms, yet all of these medications have serious, long-term, adverse side effects.

How Can Massage Therapy Help?

The careful administration of massage therapy techniques can help relieve muscle cramping, spasm, spasticity, and hand and foot paresthesias. Secondary limb and joint compensatory stiffness, contractures, and localized edema can be addressed with effective soft-tissue and range of motion (ROM) techniques. Depression can be reduced and an altered self-image can be improved by compassionate bodywork.

Because of the mercurial symptomatic picture presented by most clients with MS, therapeutic goals will shift frequently. Given both the musculoskeletal involvement of MS and the understandable accompanying stress, the following three general goals can be combined with the client’s specific concerns: 1) relieving musculoskeletal pain, spasm, and stiffness on the affected and compensating sides of the body; 2) reducing stress; and 3) helping maintain thoracic capacity and efficient breathing patterns.

Ideally, you should see your client weekly if her life and budget allow. Discuss with her if two 30-minute sessions in the same week might be better tolerated than one 60-minute session. Inconsistent, infrequent therapy yields little improvement but can still provide situational stress relief and palliative care.

Assessing Your MS Client

No two clients with MS will present with the same complaints; even the same client may present with different symptoms before each session. The following questions will help you assess the client’s immediate concerns and determine short- and long-term treatment goals:

• In which stage of MS has she been diagnosed?

• When was her last flare?

• Is she in pain today? Where?

• Is she experiencing bowel or bladder difficulty?

• When was her last injection? Which site? Is it tender?

• Which activities of daily life are the most challenging?

• How are her muscles compensating for her altered gait?

• Does she experience paresthesias? Where?

• What other health-care specialists is she seeing?

• Which specific symptoms would she like to address today?

Consider Possible Injection Sites

Most people are needle-averse, and many people with MS have to administer weekly or monthly self-injections, alternating between thighs and belly fat, and/or endure intravenous infusions to control their symptoms. Be aware of injection sites and frequency of injections or infusions, whether the injection has occurred within the last 24 hours, and whether the injection site is tender. Here are some questions and points you can consider regarding your client’s medications:

• Does my client complain about giving herself injections? Does she know about auto-injectors? 

• If my client has recently self-injected, I should not apply local heat because I could increase the rate of drug absorption; conversely, I should not apply cold, which might impede drug absorption.

• Is she bruised locally from her injections? How close can I work around her injection site, and how should I adjust my pressure in this area?

• Is her physician suggesting over-the-counter pain relievers, such as nonsteroid anti-inflammatory drugs, which can be taken an hour before each injection and then about every six hours after the injection for the first 24 hours? If she is not aware of this avenue of pain relief, suggest that she talk to her physician about this option.

Since flu-like symptoms lasting 1–3 days are a common side effect of most MS self-administered medications, remind your client to schedule massage sessions either immediately before, or a few days after, her injection.

Contraindications and Cautions

Here are some important things to consider when working with a client with MS:

• Never stretch the limbs of an MS client. You learned in massage therapy school to stretch your client’s limbs to the point of resistance, ask them to take a deep breath, and then stretch slightly beyond that point. Exactly the opposite is true when working with MS clients. Here’s why: 1) These clients can’t tolerate any form of sympathetic nerve firing, which might cause a spasm. 2) They might have an inadequate physiologic reporting mechanism to sense how far they can stretch. 3) If they have contractures, you can cause harm with even mildly overzealous passive ROM. 

• When treating or assigning homework to a client with MS, remember: ROM work must be performed only to the point of slight resistance, and then stopped. Consider scope of practice. Any further stretching or strengthening exercises should be performed by a physical therapist.

• Never work deeply or vigorously enough to overheat a muscle complex or raise the client’s core temperature. MS patients react poorly to heat, and you could initiate a flare.

• Do not apply hot packs; even a table warmer could produce too much heat and cause a flare.

• Do not use mechanical muscle vibrators to quiet a spasm, which can stimulate the sympathetic nervous system; use only your hands. 

• Be aware of the day, location, and time of the client’s last injection, and avoid working around puncture sites within 24 hours of the injection.

• Since many MS patients experience vertigo, ask permission before using any rocking techniques.

• Watch for red, inflamed, hot, or swollen areas over bony prominences. The client may not be able to feel these signs and symptoms of skin infection or breakdown. If symptoms exist, refer the client to a physician immediately.

Protocols for MS

MS is a complicated medical condition, and those afflicted endure it for their entire lives. As a result, you have an opportunity to make a significant difference in your clients’ quality of life and help them manage their level of pain. Remember, you will never accomplish all that needs to be done in one session; patience and keen listening skills will help keep each session in perspective.

Deep breathing exercises can be interjected at any point during your session. Passive ROM (remember not to fully stretch) will help ease stiffness and prevent contractures. If you notice edema, gentle effleurage and stroking performed cephalically will help. If your client experiences a spasm during your session, stay with the spasm—don’t come off the body, but instead gently hold the limb, stop massaging for a moment, and continue to apply gentle pressure. The spasm will stop and you will be able to continue your work. In this way, you are training the body to let you in, and the cumulative effects cause the muscles to more readily yield to your work.

Detailed, medium-pressure digital work into and around each joint is extremely important to maintain joint health, assist lymphatic flow, help reduce contractures, and soften hypertonic tissue. At each session, digitally explore each joint to familiarize yourself with the body so you can objectively track functional and anatomical progression or digression. The ill effects of contractures, spasticity, and spasm are bilateral, so remember to work both sides of the body.

Keeping copious and detailed SOAP notes will increase your effectiveness and help the client realize she is making progress, even if it’s minimal. Your client is seeing multiple medical specialists and dealing with an insurance company; your notes, or at least a treatment summary, may be requested by a physician or an insurer at some point.

Before your client’s first appointment, ask whether she uses a cane or wheelchair. Arrange your reception and treatment rooms accordingly. Practice transferring a client from a wheelchair to the massage table (with a colleague) to ensure a confident, accident-free process. During inclement weather, have towels available at the door so you can wipe off the wheelchair wheels and not track mud, rain, or snow into your professional area. 

Assign Self-Care Homework

After your session, you can provide much-needed holistic support as your client attempts to maintain her regular daily activities and bolster her wobbly self-image. While reminding her not to work to the point of exhaustion and to always be gentle with herself, you can offer the following homework assignments with this language:

• “Purchase a big exercise ball; blow it up until it’s firm. Place the ball next to a couch, a sturdy armchair, or the wall. Put one hand on a secure surface to steady yourself, and sit on the ball. Gently begin bouncing. Bounce as long as you can. Take frequent deep breaths. You’ll start to feel this in your thighs. When you feel the slightest bit tired, stop and rest. Then, resume bouncing. This simple exercise helps keep your thigh muscles strong and is extremely effective in maintaining your sense of balance.”

• “Find a gentle yoga or tai chi class. Both will help strengthen your balance and maintain your flexibility without overheating your central body core or major muscles.”

• “Consider swimming or a water aerobics class, but be sure the water is not too warm. You should not sweat while in the water or when getting out of the pool.”

• “Take deep breaths several times throughout the day. Inhale deeply, hold it for a few seconds, then forcibly exhale.”

• “Investigate personal deep relaxation techniques that work for you, and set aside time to practice one daily.”

• “Be sure to get enough hours of deep, restful sleep.”

You Can Make a Difference

Be aware that clients with MS are waging a battle that is subtle, frustrating, life changing—and that changes hourly. By using this knowledge to understand the disease—and your compassionate hands to help her journey—you can make a difference in your client’s body, spirit, and quality of life. 

 Charlotte Michael Versagi is a national presenter and the author of Step-by-Step Massage Therapy Protocols for Common Conditions (Lippincott Williams and Wilkins, 2011). This article was adapted from an excerpt in that textbook, which explores treatment of more than 40 medical conditions. Contact her at charlotteversagi@gmail.com.