Dementia - Lippincott Williams & Wilkinsdownloads.lww.com/.../samples/ChapterD.pdf · Dementia Nervous system A mental disorder characterized by impaired cognitive function. Cause

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DDementiaNervous system

A mental disorder characterized by impaired cognitive function.

Cause Dementia is a syndrome with many possible causes. It can result from Alzheimer’s dis-ease. Diseases affecting the basal ganglia, thalamus, and white matter in the brain (e.g., multiplesclerosis) can cause dementia. Chronic infection (e.g., syphilis) Creutzfeldt-Jakob disease (CJD),chronic subdural hematoma, some forms of hydrocephalus, late stages of Parkinson’s disease,hypothyroidism, brain damage due to head injury, hypoxia, hypoglycemia, chronic alcoholism,and encephalitis are other causes. Some psychiatric illnesses may mimic dementia (pseudode-mentia). Dementia is a result of disorders of nerve pathways and the loss of neurons in the cere-brum. (See also Alzheimer’s disease.)

Signs and Symptoms The onset of dementia is gradual, and symptoms may persist formonths to years. Unlike delirium, sleep–wake cycles are not disrupted and consciousnesslevel and attention are normal. There is a decline in intellect, memory, and personality. Theperson may be disoriented and have impaired long-term memory. Inhibition and lack of inter-est may be seen. Involuntary movements and autonomic changes are not common in this con-dition.

Risk Factors See Cause.

Medical/Surgical Treatment The cause of dementia determines the treatment. Many neu-rological, systemic, psychiatric, or other contributing causes can be controlled. In cases where notreatable cause can be found, support is required. As the severity increases, supervision may beneeded and the person may require help with daily activities.

MASSAGE THERAPY CAUTIONS AND RECOMMENDATIONS

BibliographyDelirium, dementia, and amnesic and other cognitive disorders. In Gelder MG, Lopez-Ibor JJ, Andreasen N, eds. New

Oxford Textbook of Psychiatry. 1st ed. Oxford: Oxford University Press; 2000.

Obtaining an informed consent is essential before massaging anyone with a mental disorder.In the absence of written consent, massage is contraindicated. More research is required onthe effects of massage on mentally challenged individuals. Although massage therapistsrequire training to address aspects of mental disorders that might arise during a session, spe-cial training and knowledge of specific mental conditions are necessary to modify massagetreatment plans according to the needs of individual clients. Massage is not likely to cause anyharm and may be given within the comfort levels of the client.

DepressionNervous system

A mental disorder characterized by depressed mood every day for at least 2 weeks.

Cause Depression may be due to a dysfunction of nerve signaling pathways in the brain’s pre-frontal cortex. It may also be caused by altered activity of neurons that secrete noradrenaline asa neurotransmitter. Decreased serotonin levels, changes in the communication between the pitu-

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A Handbook for Massage Therapists | D 121

itary and adrenal glands, and altered biological rhythms have also been suggested as possiblecauses.

Depression is often associated with other medical illnesses. Symptoms may be due to the psy-chological and emotional stress of coping with a disease, the disease process itself, or the med-ications being used in treatment.

Signs and Symptoms A medical diagnosis of depression is based on specific criteria fromsymptoms reported by the patient or observed by others. Some of the symptoms are sadness,indifference or apathy, irritability, loss of interest in daily activities, changes in sleep patterns,appetite loss, weight change, fatigue, loss of concentration, feelings of shame and guilt, motoragitation or impairment, and suicidal thoughts.

Risk Factors The incidence of depression increases with age, and is more common in women.There is a higher risk of depression in those with a family history, and the risk is higher when suchindividuals encounter negative life events, such as death in the family. Some people experiencedepression during specific seasons (see seasonal affective disorder). It can also be associatedwith pregnancy (postpartum depression). Also see Cause.

Medical/Surgical Treatment Treatment is aimed at reducing symptoms in the short term,and controlling symptoms thereafter. A variety of antidepressant medications are available.Psychotherapy, electroconvulsive therapy, light therapy, and patient education are other approachesthat can be combined with medication.


Massage has been shown to decrease anxiety, depression, and stress levels in depressed indi-viduals. A relaxing whole-body massage once or twice a week may be beneficial.

Obtaining an informed consent is essential before massaging anyone with a mental disor-der. In the absence of written consent, massage is contraindicated. While massage therapistsrequire training to address aspects of mental disorders that may arise during a session, spe-cial training and knowledge of specific mental conditions are necessary to modify massagetreatment plans according to the needs of individual clients. Massage is not likely to cause anyharm and may be given within the comfort level of the client.

Be careful when positioning a woman who has just had a baby. Avoid the prone position inthose who have had cesarean sections or are breast-feeding (as the breasts may be sore).Obtain medical clearance before massaging a client who has been diagnosed with postpartumdepression.

Clients suffering from depression might be taking medications, so you need to take the sideeffects into consideration.

BibliographyField T, Grizzle N, Scafidi F, et al. Massage and relaxation therapies’ effects on depressed adolescent mothers. Adoles-

cence. 1996;31(124): 903–911.Ruxh JA. Mood disorders: treatment of depression. In Sadock BJ, Sadock VA, eds. Kaplan & Sadock’s Textbook of

Psychiatry. 8th ed. Baltimore: Lippincott Williams & Wilkins; 2005; 1652–1661.Steffens L. Post-natal depression? How massage can help. Massage Austr. 2003;41:6–11.

Diabetes insipidusEndocrine system

A disorder of the posterior pituitary gland that affects the metabolism of water.

Cause Diabetes insipidus develops from insufficient secretion of antidiuretic hormone (ADH).It is usually caused by a tumor in the pituitary gland, as a complication of neurosurgery, bytrauma to the head, or by a skull fracture. In rare cases, it can be a complication of an infection.Diabetes insipidus may also result if the kidney is unable to respond to ADH (nephrogenic dia-betes insipidus). This type is usually due to a genetic defect.


D | Pathology A to Z122

Signs and Symptoms Because ADH regulates the permeability of the kidney tubules andthereby the volume of water excreted, ADH insufficiency results in excessive fluid loss in theurine. The person has polyuria (excessive urination; as high as 30 L per day in comparison to thenormal 1 L) and polydipsia (excessive thirst). Dehydration, loss of skin elasticity, dry mouth andmucous membranes, constipation, muscle weakness, and dizziness are accompanying symp-toms.


Medical/Surgical Treatment The treatment is hormone replacement therapy by injectionor by nasal spray. If tumor is the cause, surgery may be required.


Ensure that the client has the prescribed medicines on hand when scheduled for a massage.You may have to provide drinking water during the session. Keep the session short. Watch forpostural hypotension, and advise client to get off table slowly after the massage.

BibliographyGanong WF. Review of Medical Physiology. 21st ed. Los Angeles, CA: Appleton & Lange; 2003.Robertson GL. Disorders of the neurohypophysis. In Kasper DL, et al., eds. Harrison’s Principles of Internal Medicine.

New York: McGraw-Hill; 2005:2098–2101.

Diabetes mellitusEndocrine system

A chronic disease of the endocrine function of the pancreas marked by the inadequate secretion ofinsulin.

Cause Diabetes mellitus can be caused by the impaired release of insulin by pancreatic betacells, the presence of inadequate or abnormal insulin receptors on the cells, or the rapid destruc-tion of insulin even before it can carry out its action. Insulin is required for the transport of glucoseinto skeletal muscles and fat tissue. It also helps store glucose as glycogen. Insulin decreases thebreakdown of fat. For protein metabolism, insulin is required for the transport of amino acids intocells. It also increases the synthesis and conservation of proteins. Inadequate insulin will resultin opposite effects on metabolism. Figure D-1 compares the changes in blood glucose levels in anormal and diabetic individual.

Hours

Blo

od g

luco

se le

vel (

mg/

dL)

200

180

160

140

120

100

800 1 2 3 4 5

Diabetes

Normal

FIGURE D-1. A comparison of blood glucose levels in a normal and diabetic person after taking glucose. FromPremkumar K. The Massage Connection Anatomy and Physiology. Baltimore: Lippincott Williams & Wilkins; 2004.



Certain drugs that result in a loss of potassium in the urine can cause diabetes, as potassium isrequired for the normal release of insulin. Steroids, oral contraceptives, drugs that mimic the effectsof the sympathetic nervous system, certain antiepileptics, and diuretics can produce diabetes.

There are two main types: Type I, juvenile-onset diabetes; and Type II, adult-onset diabetes.Other types of diabetes are those that develop only during pregnancy (gestational diabetes) anddiabetes produced by other conditions, such as Cushing’s syndrome and chronic pancreatitis(secondary diabetes). Type I diabetes is characterized by the destruction of the pancreatic cellsthat produce insulin. Most often, the cells are destroyed by the body’s immune system when trig-gered by environmental agents, such as a virus or chemical toxin. Although it usually developsbefore the age of 40, it can occur at any age.

The cause of Type II diabetes is attributed to decreased or defective receptors for insulin in fatcells. Also, the release of insulin from the pancreas is inadequate. Type II diabetes is more com-mon in people who are overweight (especially those with upper-body obesity) and in older adults.Diabetes mellitus tends to run in families.

Signs and Symptoms The onset is abrupt in Type I diabetes and slow in Type II. Typically,both types are characterized by excessive urination, excessive thirst, and excessive hunger (thethree polys: polyuria, polydipsia, and polyphagia, respectively). High levels of blood sugar (glu-cose) trigger these symptoms. The loss of glucose in the urine forcibly increases the excretion ofwater by osmosis. The loss of glucose and water causes hunger and thirst. There is weight loss inspite of the increased appetite. Fatigue, lack of energy, dehydration, and muscular weakness areother symptoms. In general, a diabetic person is prone to infection, and wounds take longer toheal. Fungal infections are common.

The lack of insulin and resulting high glucose and free fatty acid levels has detrimental effectson almost all body systems. Complications include neuropathies, circulatory problems, and footulcers. There is a loss of sensation in the periphery, especially in the hands and feet (referred toas the glove-and-stocking effect). Effects on the autonomic nervous system can result in posturalhypotension, diarrhea, and impotence.

Eyesight is affected due to changes in the blood vessels to the retina (retinopathy). The bloodcapillaries in the kidneys are affected, possibly resulting in kidney failure (nephropathy). High lev-els of blood cholesterol contribute to the development of atherosclerosis with its associated com-plications of thrombosis and embolism (with the risk of stroke, angina, and myocardial infarction).

Foot problems are common, due to the loss of peripheral sensation, slow healing, and reduced cir-culation. In severe cases, ulcers, infection, and gangrene (with a need for amputation) can develop.

The fluctuating levels of glucose bring about other symptoms. Diabetes treatment can lead tohypoglycemia from a sudden increase in insulin levels. This can lead to symptoms of the flight-or-fight response, such as pallor, sweating, tremor, hunger, and tachycardia. Drowsiness, confusion,incoordination, seizures, and unconsciousness are other symptoms produced by an inadequatesupply of glucose to the brain.

When blood glucose levels are very high, diabetes ketoacidosis (excessive ketones in thebody, causing pH changes) results and the person has nausea, vomiting, rapid breathing, smell ofacetone on the breath, altered mood, clouding of consciousness, and even coma.


Medical/Surgical Treatment The goal of treatment is to regulate blood glucose levels andmaintain them as close to normal as possible. Diabetes is a chronic disease and requires lifelongchanges in lifestyle, and the success of treatment depends on the person’s compliance.

The treatments are dietary changes, exercise, and/or antidiabetic drugs. Antidiabetic drugs forType II diabetes stimulate the beta cells to secrete insulin. For Type I or severe Type II diabetes,insulin injections are given. A variety of insulin delivery methods are available, including subcu-taneous continuous infusion.

Pancreas transplantation is one of the newer techniques available. The possibility of utilizinggenetically engineered cells that produce insulin is being researched.


When working with diabetic clients, first determine whether the diabetes is Type I or Type II. TypeI is more serious than Type II in terms of management. Although not formally documented, expe-rience has shown that massage is beneficial to diabetics and may have an effect on daily insulin



FIGURE D-2. A diabetic ulcer in the heel of foot. From Goodheart HP. Goodheart’s Photoguide of Common SkinDisorders, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2003.

FIGURE D-3. Areas for insulin injection. From Smeltzer SC, Bare BG. Textbook of Medical-Surgical Nursing. 9th ed.Philadelphia: Lippincott Williams & Wilkins; 2000.

requirements. A relaxing and gentle massage is recommended. Ensure that these individuals arenot exposed to infections (even mild) in the clinic or massage room. Massage feedback may beinadequate in clients with decreased sensation, so monitor the pressure of strokes carefully.

Avoid working in and around diabetic ulcers, if present (Figure D-2). Insulin injection sitesshould be avoided as well, because massage can accelerate the absorption of insulin into the bloodand cause hypoglycemia (Figure D-3). Often, cell death (fat necrosis) occurs at the site of injection.

Check to make sure that the client has brought glucose or snacks to alleviate signs of hypo-glycemia. It is a good idea to have an easy source of sugar in the massage area, in case theclient experiences symptoms of a drop in blood sugar. Easy sugar sources are fruit juice, hardcandy, and honey. In case of emergency, be sure to have the contact information of the client’sphysician available.



BibliographyPower AC. Diabetes mellitus. In Kasper DL, et al., eds. Harrison’s Principles of Internal Medicine. New York: McGraw-

Hill; 2005: 2153–2180.Ganong WF. Review of Medical Physiology. 21st ed. Los Angeles, CA: Appleton & Lange; 2003.Porth CM. Alterations in blood flow in the systemic circulation. In Porth CM, ed. Pathophysiology Concepts of Altered

Health States. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2002:930–952.Linde B, Philip A. Massage-enhanced insulin absorption—increased distribution or dissociation of insulin? Diabetes

Res. 1989;11(4):191–194.

DiarrheaGastrointestinal system

The frequent passage of loose, watery stools.

Cause Of the many causes of diarrhea, the most common cause is infection. Infections canstimulate the mucosa to secrete excess water, or they can destroy the mucosa, thereby allowingwater to escape into the lumen.

Large-volume diarrhea is produced when substances in the lumen of the bowel draw excesswater from the interstitial tissue by osmosis. This type of diarrhea is seen in cases of lactase defi-ciency, high intake of magnesium-containing antacids, or when the motility of the intestines israpid. It can also be caused by infections.

Small-volume diarrhea can be caused by inflammatory conditions, such as gastroenteritis,ulcerative colitis, and Crohn’s disease. In the latter, stools contain blood and mucus. Bacterialinfection is another cause of small-volume diarrhea.

Signs and Symptoms Diarrhea (from Greek word meaning “to flow”) is considered to beacute if it lasts less than 7–14 days and chronic when lasting 2–3 weeks. In addition to the fre-quent passage of watery stools, there may be colicky pain in the abdomen. Fluid loss leads todehydration, characterized by dry and loose skin, parched mouth, and sunken eyes. The personfeels tired, weak, and faint. Nausea and vomiting are other symptoms.

Risk Factors Infectious diarrhea is transmitted by fecal contamination of water or by contactwith clothes or other articles soiled by a person with diarrhea. It can also be transmitted by foodpoisoning, the presence of bacteria in uncooked meat, or sexual activity with an infected individ-ual. Inadequate sewage disposal and water supplies, lack of refrigeration, overcrowding, and lackof personal hygiene are contributing factors. Intravenous drug users and individuals engaging innonhygienic sexual activity are particularly susceptible.

Medical/Surgical Treatment Treatment includes electrolyte and fluid replacement,administered orally or intravenously. Antibiotics may be used in specific types of infectious diar-rhea. Drugs that slow the movement of the intestines may be used in situations where there is noaccompanying fever or blood or mucus in the stools (i.e., diarrhea not caused by infection).Treatment of chronic diarrhea varies according to the cause.


Avoid massaging clients with an acute case of diarrhea until all symptoms have abated. Thistype is usually due to infection, and you must prevent spreading infection to yourself andother clients inadvertently. If you have diarrhea due to infection, refrain from work until allsymptoms have subsided. For clients who have chronic diarrhea, avoid massaging theabdominal area.

BibliographyPowell DW. Approach to the patient with diarrhea. In Tadataka Y, et al., eds. Textbook of Gastroenterology. 4th ed.

Philadelphia: Lippincott Williams & Wilkins; 2003.



Cause Dislocation is usually caused by trauma to the joint. It can also be caused by weaknessof the supporting structures, as in paralysis of the muscles supporting the joint or lax ligaments.In some cases, dislocation is congenital, especially in the hip and knee joints. Subluxation, thepartial displacement of the articulating surfaces of the bones in the joint, can lead to dislocation.

Signs and Symptoms The symptoms are severe pain and deformity (abnormal position orappearance of a limb or joint area). The pain and the protective spasm of surrounding musclesinhibit movement.

A snapping sound may be heard when the injury occurs. The surrounding tissues (articular car-tilage, joint capsule, ligaments, tendons, blood vessels, and nerves) may also be injured. Signs ofacute inflammation––pain, swelling, redness, heat, and loss of function––are common.

Dislocations can be complicated by joint laxity and a tendency of the joint to dislocate repeat-edly. Those with recurrent dislocations are more prone to developing osteoarthritis. Examples ofdislocations are shown in Figure D-4.

DislocationMusculoskeletal system

A disturbance to the normal relationship of bones in a joint, resulting in complete displacement ofthe articulating surfaces.

Glenoid fossa

Ulna

Humerus

Radius

Clavicle

Scapula

(a)

(b)

FIGURE D-4. (a) Dislocation of the shoulder. (b) Dislocation of the elbow. From Neil O. Hardy, Westpoint, CT.

Risk Factors Any joint can dislocate, depending on the force applied, but certain joints aremore susceptible to dislocation. The glenohumeral joint in the shoulder is most frequently dislo-cated due to the shallow glenoid fossa. Other joints include the acromioclavicular (shoulder sep-aration), the metacarpal, and the interphalangeal joints.

Medical/Surgical Treatment The articulating surfaces of the bones are brought back intonormal position by joint reduction. With or without anesthesia, depending on the joint in ques-tion, the patient is positioned appropriately and traction is applied. In some cases, surgery may



be required to reduce the joint and to repair the torn tissue around the joint. After reduction, thejoint is immobilized for about 3 weeks to promote healing. Rest, ice, compression, and elevationare the best forms of treatment in the early stages. This is followed by range-of-motion (ROM)exercises to mobilize the joint and to strengthen the muscles around it.


A thorough history should be taken in order to find out how the dislocation occurred and thedetails of treatment. If surgery has been performed, you should contact the physician in orderto find out whether massage is contraindicated.

Special TechniquesMassage is contraindicated in the local region during the acute and subacute stages. If thejoint has been splinted, the splint should not be removed. The dislocated joint should not beput in the same position that caused the injury. Muscles compensating for the injured regioncan be massaged using broad strokes. Lymphatic drainage techniques by a trained practitionermay be used in the regions proximal to the injury. If the client is taking painkillers, feedback islikely to be inadequate because of reduced sensations. Deep massage is therefore contraindi-cated. Passive ROM movements may be performed on proximal joints (provided the same mus-cles do not cross the injured joint as well).

In the chronic stage, the goal of massage is to prevent or reduce formation of adhesions.Deep moist heat may be applied to soften the tissue and increase blood flow to the area, ifusing heat is within the scope of your practice. Cross-fiber friction and longitudinal musclestripping can be used over the joint followed by the application of ice, if that is within yourscope of practice. Gentle, passive ROM exercises may also be performed (excluding the direc-tion in which the injury occurred).

Because many of the tissues in and around the dislocation have a poor blood supply, heal-ing takes longer. It can take 4–6 months to fully recover from a dislocated joint. You must becautious when treating clients with a history of dislocation.

BibliographyRattray F. Dislocation. In Rattray F, Ludwig L. Clinical Massage Therapy—Understanding, Assessing and Treating

over 70 Conditions. Toronto: Talus Inc.; 2000:339–358.

Diverticular disease (Diverticulitis; Diverticulosis)Gastrointestinal system

An intestinal disorder characterized by the presence of diverticula, bulges that protrude through themuscular walls of the GI tract.

Cause The disease results from increased pressure in the lumen of the bowel, which pushesthe inner lining through the muscular layer, especially in the weak areas. Potential weak areas arethe locations where blood vessels enter the intestines. It is most often seen in the sigmoid colonjust above the rectum (Figure D-5). Diverticulosis can be congenital or acquired.

Signs and Symptoms In the more common type, diverticulosis, there is no inflammation;the person has no symptoms or has mild pain in the lower left quadrant of the abdomen. The painmay be relieved by defecation. The person may also have alternating diarrhea and constipation.There may be blood in stools. In diverticulitis, the diverticula are inflamed, and the symptomsinclude lower left abdominal pain, excess gas formation, nausea, low-grade fever, and irregularbowel movements.

Sometimes, the diverticula can form abscesses and rupture, resulting in acute pain in lowerleft abdomen, along with spasm and rigidity of the abdominal muscles. The reaction to the fecalmatter that has leaked into the abdominal cavity can cause peritonitis with high fever and chills,and the person may go into shock.

If the condition is chronic, inflammation and healing by fibrosis can cause the lumen to narrow,resulting in intestinal obstruction. Constipation, ribbonlike stools, and abdominal distention aresome of the symptoms of partial obstruction.



Risk Factors It is more common in the United States. About 50% of people over age 50 areaffected. Inadequate dietary fiber, a sedentary lifestyle, and irregular bowel habits (such asneglecting the urge to defecate) predispose to this condition.

Medical/Surgical Treatment If asymptomatic, diverticular disease is left untreated. Ifsymptoms are present, it is controlled by altering the diet, and taking stool softeners. Patients areencouraged to increase their intake of water, vegetables, fruits, whole-grain bread, wheat, andbran.

If the diverticula are inflamed and infected, as in diverticulitis, antibiotics and drugs to reducespasm are given. In severe cases, surgery can be performed. The diseased portion of the colon isremoved and the healthy parts rejoined, or the end of the colon is opened onto the surface of theabdominal wall (colostomy).


Rectum

Anus

Sigmoidcolon

Lumen

Diverticula

FIGURE D-5. Diverticulosis in the sigmoid colon. From Neil O. Hardy, Westpoint, CT.

Massage is contraindicated during the acute stage. After the acute stage has passed, gentleabdominal massage in older clients can help regulate bowel movements. Avoid increasedpressure in the abdomen or rigorous massage of the abdomen in older clients even if there isa complaint of constipation, as diverticula, if present, can be ruptured.

BibliographyPorth CM, ed. Pathophysiology Concepts of Altered Health States. 6th ed. Philadelphia: Lippincott Williams &

Wilkins; 2002:846–848.

Down syndrome (Trisomy 21)Nervous and cardiovascular systems

A genetic, congenital disorder marked by mental and physical impairments.

Cause Down syndrome is caused by the presence of three instead of two copies of chromo-some 21, usually due to defects in the way the ovum or sperm divide. The possibility of other sib-lings having Down syndrome depends on the type of abnormality in the chromosome.



Signs and Symptoms The child is mentally challenged and typically has slanting, almond-shaped eyes; a protruding tongue; and a small skull, mouth and chin (Figure D-6). The develop-ment of teeth is slow. The bridge of the nose is flat, and the ears are small and rounded. The per-son has short stature, with short limbs, small hands, and flat feet with a wide gap between thefirst and second toes. Muscle tone is decreased, joints are lax and hyperflexible, and balance andcoordination are poor. Pelvic bone abnormalities may be seen. There may be associated devel-opmental defects of the heart.

FIGURE D-6. Down syndrome. Notice the small, rounded head, mouth, and chin; the flattened nasal bridge;the slanting almond-shaped eyes; the small, low-set, shell-like ears; and a relatively large tongue. From BickleyLS, Szilagyi P. Bates’ Guide to Physical Examination and History Taking. 8th ed. Philadelphia: Lippincott Williams &Wilkins; 2003.

Risk Factors The incidence is higher if the birth of the child occurs when the mother is older than34 or the father older than 42. Down syndrome can be inherited from the mother or father. Exposureto radiation and certain viruses also increases the chances of having a child with Down syndrome.

Medical/Surgical Treatment As in all genetic disorders, prevention is the most effectiveway of dealing with the condition. Genetic screening and counseling are available.


Massage can help increase muscle tone and improve balance and coordination. Be cautiouswhile working with and around joints, which are lax and hyperflexible. Special training may berequired for working with these clients on a regular basis, in order to understand the condi-tion, the clients, and the challenges they face.

BibliographyBianchi DW, et al., eds. In Fetology: Diagnosis & Management of the Fetal Patient. 1st ed. New York: McGraw-Hill; 2000.Trisomy 21 syndrome (Down syndrome). In McMillan JA, et al. Oski’s Pediatrics. 4th ed. Philadelphia: Lippincott

Williams & Wilkins; 2006.

Dupuytren’s contracture (Dupuytren’s disease)Musculoskeletal system

A progressive, painless thickening and tightening of the palmar aponeurosis, resulting in flexion con-tracture of the fourth and fifth fingers.



Cause Usually the cause is not known. In some cases, the condition is inherited. The palmar aponeurosis is a broad, thin, tough sheet of connective tissue that stretches from

the palmaris longus tendon at the front of the wrist and radiates to its insertion at the proximaland middle phalanges of the fingers. The fibers are organized in longitudinal, transverse, andanterior–posterior directions; they help counteract forces acting on the palm of the hand. InDupuytren’s contracture, the connective tissue thickens and shortens.

Signs and Symptoms At first there is a small, thickened nodule in the middle of the palmclose to the ring finger (Figure D-7a). The skin may appear dimpled. The thickening spreads fromthis point, eventually forming cordlike bands. The fourth and fifth fingers remain flexed at the

(a)

(b)

Dimpled skin

Thickenedaponeurosis

formingcordlike

bands

FIGURE D-7. Dupuytren’s contracture. (a) Dimpled skin and thickened aponeurosis. (b) Flexed metacar-pophalangeal and interphalangeal joints of the 4th and 5th fingers. From Moore KL, Dalley AF. ClinicallyOriented Anatomy. 4th ed. Baltimore: Lippincott Williams & Wilkins; 1999.



metacarpophalangeal and interphalangeal joints (Figure D-7b). The resulting restricted move-ment in the small joints of the hand can lead to arthritis. Signs of inflammation may be present,and pain may be felt on passively extending the fingers. The condition is usually bilateral.

Risk Factors The condition is more common in older men, alcoholics, and people with dia-betes or epilepsy. Dupuytren’s contracture may be associated with occupations that require theprolonged, forceful gripping of tools.

Medical/Surgical Treatment Splinting of the hand or surgery (palmar fasciotomy) may bedone to release the contracture of the palmar aponeurosis. In some clients, a similar contracturemay be seen in the sole of the foot.


If the client is taking antiinflammatory medications, massage should be avoided becauseclient feedback may not be adequate. Contact the physician if the client has had recent surgi-cal treatment, and avoid massage until the incision site is completely healed (usually about 24days). If signs of inflammation are present, ice application is beneficial, if the use of ice iswithin your scope of practice. In subacute and chronic stages, the aim is to maintain ROM inthe joints and to prevent adhesions and contractures. If it is within your scope of practice,using deep moist heat helps soften the connective tissue prior to the massage. Friction strokesfollowed by ice should be used to reduce adhesions. Use broad strokes to improve the circu-lation in the muscles of the forearm.

Special TechniquesThe palms should be kneaded thoroughly, both longitudinally and transversely, to stretch thepalmar aponeurosis (Figure D-8). Stretch the fingers in a gentle, slow, and sustained manner,holding the stretch for 15–30 seconds. Passively move all the small joints of the hand.Resistance exercises can improve the strength of the muscles. Advise the client to stretch thefingers many times during the day. This can be done easily, with the client standing and rest-ing the palm on a table. The fingers are stretched and maintained in this position with the otherhand. By moving the body over the arm, the wrist can be simultaneously extended.

Massage is recommended for half an hour, once a week for 6 weeks, followed by reassess-ment.

(a) (b)

FIGURE D-8. Double-thumb and single-thumb techniques for releasing the palmar aponeurosis. From Hend-erickson T. Massage for Orthopedic Conditions. Philadelphia: Lippincott Williams & Wilkins; 2003. (continued)



BibliographyHendrickson T. Massage for Orthopedic Conditions. Philadelphia: Lippincott Williams & Wilkins; 2003:394,

422–424.Rattray F. Dupuytren’s contracture. In Rattray F, Ludwig L. Clinical Massage Therapy—Understanding, Assessing and

Treating over 70 Conditions. Toronto: Talus Inc.; 2000:991–999.

(c) (d)

FIGURE D-8. (continued) Double-thumb and single-thumb techniques for releasing the palmar aponeurosis.

DysmenorrheaReproductive system

Abdominal pain during menstruation excessive enough to prevent normal activity and requiringmedication.

Cause The cause is not known in most cases of dysmenorrhea. It can be due to other diseases,such as endometriosis, fibroid tumors, or pelvic inflammatory disease. Increased levels ofprostaglandins in the uterus have been implicated.

Signs and Symptoms Dysmenorrhea is characterized by lower abdominal pain 1–2 daysbefore or on the first day of menstruation. The pain may be intermittent. It is often accompaniedby headache, nausea, and vomiting. Irritability and dizziness are other symptoms.


Medical/Surgical Treatment Primary dysmenorrhea with no physical cause is treated withantiprostaglandins, such as ibuprofen, or other painkillers, such as aspirin. Counter pressure,heat applications, and exercise can be beneficial. Sometimes hormone therapy such as oralcontraceptives is used. Secondary causes should be ruled out in all cases of dysmenorrhea, andtreatment directed toward the cause, if found.


A relaxing whole-body massage with a focus on the lower back and abdomen is recommended.

BibliographyRapkin AJ, Howe CN. Pelvic pain and dysmenorrhea. In Berek JS, ed. Berek & Novak’s Gynecology. 14th ed. Philadel-

phia: Lippincott Williams & Wilkins; 2007.



Cause Any factors that affect the structures and nerves involved in swallowing can cause dys-phagia. Mechanical factors include foreign objects in the throat or esophagus, conditions thatcause narrowing of the lumen such as inflammation or strictures (e.g., congenital strictures orthose due to ulceration; Crohn’s disease), or pressure from outside the esophagus (e.g., cervicalspondylitis, enlarged thyroid gland, aortic aneurysm, or tumors). Alternately, the neuromuscularstructures may be affected, for example, muscle paralysis, lesions of the vagus and glossopha-ryngeal nerves that innervate some of the swallowing muscles, and defects in the swallowing cen-ter in the brain.

Signs and Symptoms The person feels as if there is something obstructing the passage offood in the throat. If the cause is mechanical, usually there is difficulty in swallowing solids andnot liquids. If the duration of the condition is short, it may be due to inflammation. If the dyspha-gia progresses, invariably it is due to abnormal growths.


Medical/Surgical Treatment Treatment is based on the cause.


DysphagiaGastrointestinal, nervous, and musculoskeletal systems

Difficulty in swallowing.

Encourage the client to seek medical help if there is difficulty in swallowing. Massage may begiven for general relaxation. The client might be most comfortable in a seated or half-lyingposition.

BibliographyGoyal RK. Dysphagia. In Kasper DL, et al., eds. Harrison’s Principles of Internal Medicine. 17th ed. New York:

McGraw-Hill; 2008: 237-240.

DyspneaRespiratory and cardiovascular systems

An abnormal and uncomfortable awareness of breathing.

Cause Dyspnia occurs whenever the work of breathing is increased—that is, when there isabnormal or excessive activation of the respiratory center in the brainstem. The most commoncauses of dyspnea are obstructive diseases of the airways (e.g., asthma, chronic bronchitis,bronchiectasis); diffuse lung diseases (e.g., pneumoconiosis); pulmonary emboli and edema; orheart disease (e.g., congestive heart failure).

Signs and Symptoms Dyspnea may be described by the person in various ways, such asfatigue or tightness in the chest, a choking sensation, or difficulty in getting enough air into thelungs. Some may have dyspnea only when lying down (orthopnea), in lateral lying position (tre-popnea), or in an upright position (platypnea), while others may have periodic dyspnea at night(paroxysmal nocturnal dyspnea).


Medical/Surgical Treatment Treatment depends on the cause.




Clients with dyspnea may feel comfortable in a seated or half-lying position. Keep the sessionshort, and focus on the respiratory muscles and other muscles of the thorax.

BibliographySchwartzstein RM. Dyspnea and pulmonary edema. In Kasper DL, et al., eds. Harrison’s Principles of Internal

Medicine. 17th ed. New York: McGraw-Hill; 2008: 221–225.


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