Don’t accept the misconceptions. “Neuropathic pain is a lifelong condition.” “Severe neuropathy leads to amputation.” “Medication is the only way to reduce the pain.” 
While there are some truths to these statements, especially if the condition is left untreated, neuropathy need not be a lifelong condition, nor does it need to lead to amputation. As a massage therapist, you can profoundly and permanently affect neuropathic symptoms in many of your clients. To do so, you have to be willing to go up against commonly held beliefs, but the results could be life changing.
Case studies suggest that frequent application of the treatment protocol and daily self-care outlined here can significantly reduce the painful symptoms associated with neuropathy and enhance quality of life—including reduction of medication levels. Pregangrenous tissue in diabetic patients can be returned to health, and clients who previously lived with extreme foot pain can achieve the full use of pain-free limbs.
What is Neuropathy?
For this look at neuropathy, we’ll be discussing two specific types: diabetic peripheral neuropathy (DPN) and chemotherapy-induced peripheral neuropathy (CIPN). Both involve damaged and painful distal sensory and motor nerves. In DPN, the cause is uncontrolled blood glucose, while CIPN is a side effect of chemotherapy.
There are several symptoms shared by both DPN and CIPN:
• Initial, subtle discomfort in the hands and feet, sometimes including a feeling of reduced sensation described as “stocking and glove.”
• Progressive paresthesia symptoms such as burning, tingling, numbness, and a pins-and-needles sensation. 
• Clumsiness, deep muscle aches and pains, spasm, and loss of strength.
• In advanced cases, allodynia (pain from a stimulus that would normally not cause pain, such as the weight of a bedsheet on the toes).
Approximately 30–50 percent of all diabetics will eventually have symptoms of DPN, including about 10–20 percent of newly diagnosed patients and 50 percent of all elderly patients. The most serious comorbidities include foot ulceration and lower-extremity amputation. DPN is characterized by uncontrolled (high) blood glucose, vascular insufficiency, and degeneration of nerve fibers due to lack of oxygen. It presents with mild onset, usually initial discomfort, and later progresses to acute pain, open wounds, and ulcers. If the decline is not controlled, amputation is a risk. DPN is prevalent in people who smoke, drink alcohol heavily, are hypertensive, or who have a long or uncontrolled history of diabetes mellitus.
CIPN is caused by the administration of neurotoxic (nerve-damaging) chemotherapeutic drugs. With CIPN, the sensory nerves are most often affected. After a mild onset, discomfort increases with each additional chemotherapy dose, usually moving proximal as the pain worsens. The duration of CIPN is usually several months, with peak discomfort at 3–5 months after the final chemotherapy dose. Most symptoms diminish within a year and CIPN is rarely irreversible. The condition is more prevalent in chemotherapy patients who drink alcohol heavily or are severely malnourished.
The most serious concern for CIPN patients is that the pain or discomfort can become so severe that the patient may choose to discontinue cancer treatment. Even if the discomfort itself is minimal, it may be the last straw for a patient dealing with a complicated medical journey and other side effects. Oncologists generally take great measures to try to reduce the symptoms of CIPN.
Pathophysiology
To better understand these conditions, let’s do a quick anatomy review. The two main divisions of the nervous system are the central nervous system, which includes the brain and spinal cord, and the peripheral nervous system (PNS).
The PNS includes the nerve fibers that transmit sensory information to the brain (for example, “this cup is hot”) and the necessary motor signals back from the brain to the muscles to cause the desired response (quickly putting the cup down).
To function properly, these long and fragile nerves must regularly receive generous amounts of carefully regulated nutrients and oxygen, and the body’s blood glucose level must remain stable. Clinical studies indicate the efficient functioning of the nerves is directly related to the level of oxygen they regularly receive. When the blood glucose level spikes or remains high, or when chemotherapy severely reduces the ability of peripheral nerves to utilize oxygen, there is a greater risk of DPN and/or CIPN.
Peripheral neuropathies, starting as innocuous and mildly uncomfortable conditions, can lead to a severe decrease in the patient’s quality of life, including potential amputations in the case of diabetic patients. Understanding the seriousness of these conditions is paramount if you are to properly perform the protocol and teach clients how to take care of themselves (see Client Homework, page 88).
Medical Diagnosis and Treatment
Physicians’ diagnostic methods for both DPN and CIPN include simple reporting of the location, duration, and intensity of the sensory or motor disturbance; observance of heel-toe gait; and various tests including electrodiagnostic, muscle strength, pin-prick, cranial nerve, and nerve conduction tests. As a massage therapist, you can assess/observe symptoms, document sensory and motor disturbances, and observe heel-toe gait.
Early symptoms of both neuropathies are often treated with physical therapy to address muscle weakness, pain, and the loss of balance, mobility, and strength. Transcutaneous electrical nerve stimulation units are recommended for pain control. Physical therapists also teach patients vigilant skin care, and they can attend to open wounds, should the condition progress.
Acupuncture is an effective tool for pain management in both types of neuropathy and psychological counseling can help with quality-of-life issues.
Preventive methods for DPN include rigorous blood glucose regulation following a diabetes diagnosis. Good nutrition and regular exercise are paramount, and combinations of B vitamins are often prescribed to reduce early-onset paresthesia. No preventive measures have yet been identified for CIPN.
Common Medications
Be aware of medications your client may be taking to alleviate neuropathy, so any potential contraindications and side effects may be considered. A potential benefit of the massage protocol described here is decreasing the client’s dependence on medication.
Doctors are generally reluctant to prescribe medication for CIPN, since it is considered a short-term condition and the patient is already receiving so much other medical treatment. However, if CIPN persists a year or more after chemotherapy, either Lyrica or Neurontin is usually prescribed. For DPN, the following are often prescribed:
• Anticonvulsants, such as gabapentin (Neurontin) and pregabalin (Lyrica).
• Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Motrin, Advil) and naproxen (Aleve, Anaprox, Naprelan, Naprosyn).
• Selective serotonin reuptake inhibitors (SSRIs), such as paroxetine hydrochloride (Paxil) and sertraline hydrochloride (Zoloft).
• Selective serotonin-norepinephrine reuptake inhibitors (SNRIs), such as duloxetine (Cymbalta).
• Topical creams such as capsaicin.
• Tricyclic antidepressants, such as amitriptyline hydrochloride (Apo-Amitriptyline, Endep).
• Tricyclic antidepressants, such as imipramine hydrochloride (Tofranil).
A Massage Therapy Protocol That Works
With physician approval, I have used the protocol described here on hundreds of oncology patients at the Beaumont Cancer Institute in Royal Oak, Michigan. The protocol continues to be used for these patients, and I use and teach this protocol across the country.
Neuropathy Massage protocol
(This protocol is for the feet, but the same technique can be used for hands. Always perform protocol on both feet or both hands.)
Position the client comfortably. Cleanse the feet, if desired.
Gently examine both feet for cold patches, open sores, and reddened or purple blotches, while simultaneously applying experimental pressure to determine the client’s pain tolerance. (Cold spots are cause for concern and the patient should be referred to a doctor, but it’s not an emergency situation. Open sores are always a massage contraindication. Bluish skin, grey skin, or little black dots are cause for an immediate referral to a doctor.)
Stroking, light pressure, using your whole hand.
• Plantar and dorsal surfaces of one foot.
• Gastrocnemeus, tibialis anterior; all tissue below the knee to the toes.
Compression, light pressure, using your whole hand.
• Plantar and dorsal surface of one foot.
• Gastrocnemeus, tibialis anterior; all tissue below the knee to the toes.
Stretching, to the client’s tolerance, full range of motion.
• Every toe joint.
• At the ankle.
Digital kneading, light pressure, to the client’s tolerance.
• Each toe from the distal tip to the base of the toe.
• Work all toe surfaces, front, back, in between.
Digital kneading, light pressure, to the client’s tolerance.
• Between each ligament of the foot, working from the base of the toes to the ankle.
• Knead the ball of the foot.
• Knead the arch of the foot.
• Knead the heel of the foot.
Repeat the digital kneading step of all toes and the entire surface of the foot with your goal being to massage to the bone. It may take a few sessions before the client’s tolerance is high enough to allow this. Whether or not she is performing her daily self-care routine correctly (see Client Homework, page 88) will directly affect tolerance levels. In each session, progress from light work to massaging as deeply as you can, to her tolerance. This digital kneading takes up the bulk of your protocol.
Effleurage, medium pressure.
• From the toes to the ankle, around the ankle, to the knee.
Effleurage, petrissage, effleurage, deep pressure.
• From the ankle to the knee.
Effleurage, petrissage, effleurage, digital and knuckle kneading, deep pressure.
• All toes, the plantar and dorsal surfaces of the foot, the ankle, and the calf, to the knee.
Stroking, using your whole hand.
• From the toes to the knee, anterior and posterior surfaces.
If you have the time, it’s pleasant to apply hot towels to the feet at the finish to soothe the feet and remove any excess lubricant.
Why does it work? All nerves need oxygen to function and survive. As one of my earliest instructors at massage therapy school put it, “A nerve in pain is a nerve screaming for oxygen.” Although DPN and CIPN have multifaceted causes, one recurring factor is that the peripheral nerves are in oxidative debt. One of the greatest benefits of massage therapy is its ability to increase localized circulation. If DPN and CIPN are on some level caused by a lack of cellular oxygen (poor local circulation), then any techniques that increase local circulation to the peripheral nerves should decrease symptoms.
Assess Your Client
When seeing a client who has been diagnosed with DPN or CIPN, your intake questions should clarify the location and severity of signs and symptoms. Perform a careful, detailed visual examination of the hands and feet, looking between fingers and toes and inspecting both dorsal and plantar surfaces.
Gentle touch should also investigate significant changes in tissue temperature. Pregangrenous tissue can feel alarmingly cold. Gentle pressure is applied to the affected tissue with careful observance of the client’s response. Using the 0–10 pain scale will help the therapist determine the aggressiveness with which she can then apply the appropriate protocol.
Charting all observations and responses will prove invaluable as the therapeutic relationship progresses, and in reporting improvement to the client’s physician.
Self-Care Compliance
Client self-care is a major component of this protocol. In fact, 15-minute self-care sessions every day, for each hand and/or foot, for the duration of symptoms, is absolutely essential. You must convince the client to perform her homework assignments daily; this is not optional, unless she is willing to visit you every day. Usually, you will offer one or two one-hour sessions during which you teach the self-care protocol to both the client and her caregiver.
Understand the Work
The session protocol itself is simple but extremely detailed, working into every crevice of the hand, foot, fingers, and toes (see Neuropathy Massage Protocol, page 86). If the 60-minute session includes two feet, you will spend 30 minutes on each foot. If the session includes both hands and feet, you will spend 15 minutes on each hand and then each foot.
It may seem incomprehensible that you can work on a foot for 30 minutes, but you are trying to displace, wash out, and return venous blood from the depths of this foot or hand and allow the body to replace it with freshly oxygenated arterial blood.  
Your goal is to massage to the bone, which means your massage works through all superficial tissue until it pushes against underlying bone. Although this may seem counterintuitive for a client with painful neuropathy, you will start very gently. It often takes several sessions, performed with gradual intensity, to get the client to the level that she can experience maximum therapeutic effectiveness—and then can be graduated to perform solo at home.
For the client’s understanding and compliance, you must be able to explain oxidative debt and how therapeutic massage can help by increasing local circulation, combined with a finely honed diplomacy. Explain you are going to start gently and only progress to her tolerance.
The Session
This protocol can be performed with the client supine on a massage table, or seated comfortably (however, it cannot be performed in a massage chair). The client need not disrobe more than necessary to expose the hands and feet.
Since the work includes detailed massage between the toes and can last for up to 30 minutes, you may want to wash the client’s feet first. Use a basin and towel, or one warm, wet towel and one dry towel. Do not use soap or other cleansing products, as the feet may be sensitive to chemicals. If washing the feet is not possible, you can wear nonlatex gloves during the entire procedure to protect your hands.
All massage techniques are performed in the cephalic direction, toward the head. Stroke the client’s feet or hands frequently during this protocol, to give her a chance to relax from the fear of being hurt, and to assess tissue temperature.
After you are thoroughly familiar with performing the 60-minute protocol as written, it can be altered according to your client’s needs, the time available, and your own creative instincts. Trust yourself.
You Can Make
a Difference
Think about your ability to save a foot from amputation. Think about your client’s ability to put on shoes without pain, walk upright, and enjoy life again. This deceptively simple protocol can make a profound difference for you and your clients.
 Charlotte Michael Versagi is a national presenter and the author of Step-by-Step Massage Therapy Protocols for Common Conditions (Lippincott Williams & Wilkins, 2011). Contact her at charlotteversagi@gmail.com.

Client Homework
This self-care assignment must be done daily for your massage therapist’s work to be effective. It’s very important for you to make time every day to perform this therapy. It complements the work you receive from your practitioner. You’ll spend at least 15 minutes on each foot.
? Start by lightly massaging both feet. Squeeze and massage as deeply as you can tolerate, but don’t cause pain.
? Perform this range-of-motion (ROM) exercise: “write out” the whole alphabet using your toes and ankle joint to trace the shapes of every letter in the air.
? Grasp the tip of one toe and massage and squeeze it as deeply as you can tolerate. Work on the entire toe from top to bottom. Repeat for all toes. Deeply stroke the skin of both feet toward your knee.
? Now, squeeze and massage all the tissue of your feet between the toes, on both the front and back surfaces of your foot. Massage as deeply as you can tolerate—squeezing, pressing, and massaging every inch.
? Aggressively stroke both feet from your toes to your knee with strokes moving in the direction of the knee.  
? Massage your calves.
? Repeat the ROM exercise a second time.
? Throughout the day, whenever you can, take your shoes off and rub your feet against the floor, bend your toes, and perform your ROM exercise. You can also roll a tennis ball under the sole of your bare foot.
? Although your feet may be tender when you begin this homework, your goal is to eventually work so deeply you can feel bone underneath your skin. This may take some time. Be patient, and work as deeply as you can each time. Your most important goal is consistent, daily, deep work.

Contraindications and Cautions
If you discover nonresponsive cold tissue, or you notice any purplish blotches or breakdown of skin, refer the client to her physician immediately.
? If a cancer patient discusses the possibility of stopping her chemotherapy because of her irritation with CIPN, advise her to speak to her physician.
? Keep orange juice and small candy bars handy when treating diabetic patients.
? Open wounds or sores are contraindications for local massage.
? A high percentage of cancer patients develop foot fungus as a result of a compromised immune system. This is highly contagious and can be transmitted to the therapist. It is not wise, even if gloved, to work on a toe that is manifesting fungus until the condition is completely cleared up.
? If the foot has an unusually strong odor, noticeably different from an odor previously noted, this may be a sign of impending gangrene or infection; refer the client to a physician immediately.

Resources
Dougherty, P.M. “Persistent Chemoneuropathy in Patients Receiving the Plant Alkaloids Paclitaxol and Vincristine.” Cancer Chemotherapeutic Pharmacology (March 2013).
Gilbert, M. and T. Armstrong. “Understanding Chemotherapy-Induced Peripheral Neuropathy.” Coping (2006): 26–7.
Polomano, R.C. and J.T. Farrar. “Pain and Neuropathy in Cancer Survivors.” American Journal of Nursing 106 (2006): 39–47.
Rosson, G.D. “Chemotherapy-Induced Neuropathy.” Clinics in Podiatric Medicine and Surgery 23 (2006): 637–49.
WebMD. “Understanding Peripheral Neuropathy—The Basics.” Accessed December 2013. www.webmd.com/brain/understanding-peripheral-neuropathy-basics.

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