An unexpected development
Introduction
Rose was scheduled to begin graduate school in the fall of 2017. The healthy 23-year old graduate student began to develop mysterious hives, followed by a kidney infection, then persistent abdominal pain, and became unintentionally familiar with the local emergency room before a colonoscopy during her third hospitalization finally led to her diagnosis – ulcerative colitis.
Ulcerative colitis is a chronic autoimmune disorder of the large intestine with acute flares of digestive and systemic symptoms, including fatigue, nausea, fever, anemia, bloody stool, abdominal pain, sore joints, and skin irritation. Causes are unclear, though genetics may play a role. The goal in treating ulcerative colitis is to prolong the periods of remission between flares. In the case of severe, uncontrollable symptoms, the entire large intestine is removed, and the end of the small intestine is attached to an opening formed in the side of the abdominal wall. A disposable pouch is attached to the resulting port, called a stoma, to collect food wastes as they are created. 2
Rose left the hospital with a prescription for an anti-inflammatory suppository, but few other tools for managing her condition. Though her severe symptoms had resolved, she was still dealing with intermittent symptoms of swollen hands, nausea, constipation, and relatively persistent fatigue, though she was not always sure if they were attributed to her inflammatory bowel disease. She had done some research to try and adjust her diet but found the available resources more overwhelming than helpful, suggesting conflicting solutions or describing horror stories. She tended to simply ignore her stress and discomfort until it became severe.
Like many other clients with bowel disease, she did not seek massage to directly manage her ulcerative colitis, but rather the stress, tension, and other factors that may result from or contribute to her condition.3 We met in the fall of 2018 as I was seeking practice clients. As a massage therapy student with an interest in digestive pathologies, I was delighted that Rose was willing to track and share her symptoms with me before and after a series of nine massages over a three-month period.
Exploring abdominal massage
Methods
It took about three sessions of experimentation to find the right flow to our sessions. Our first instinct, in massage is often to rub what hurts, but with a stomach pathology to consider, I was not sure if or how to massage the abdomen, or for how long. In researching I learned that deep work within the client’s comfort was indicated except during acute flares of the condition.4 I consulted a practitioner of Mayan abdominal massage,5 who recommended giving 20-30 minutes of the session to abdominal work, using any appropriate stroke I was trained in. Fortunately, my teachers were a wealth of abdominal techniques! Working with the abdomen towards the beginning of the massage allowed us to explore lots of those strokes without rushing. Since the digestive system operates optimally in the parasympathetic state, I strove to make our sessions feel safe, secure, and soothing. I chose a slower pace, embracing Swedish strokes for the foundation of the work
One of Rose’s goals was to become more aware of her body. To facilitate this, I began and ended each session with a full body still touch “check in.” I held her feet and asked her to notice how they felt in that moment, then progressed in the same way to her calves, knees, thighs, hips, belly, ribs, chest, shoulders, upper arms, hands, neck, and finally her head. In the first few sessions I talked her through this, then gradually talked less and less and moved through the sequence more quickly. I encouraged her to check in with her body in the same way on her own, just for a minute or two each day. She liked this a lot, so we continued it through all our sessions.
Our flow in place, our sessions began to feel productive. We were able to give the abdomen a generous proportion of the session; to really layer through the abdominal tissue and address the deeper structures. We often spent a full 30 minutes there: I slowed down the colon stroke, took my time with sun and moon, pulled and wrung at several different angles, worked cross fiber around the circle made by the lower ribs and anterior ilium, included some myofascial stretching and lifting, addressed the diaphragm and intercostals, and layered through the abdominal muscles. I tried using castor oil as a lubricant on the abdomen and found it to be perfect for myofascial and deep tissue work, while still allowing for slow Swedish massage strokes. For the rest of the time, I incorporated the whole body generally, the back specifically, and gave a little extra time to either the anterior legs, posterior legs, or arms, alternating in each session. This allowed me to address the body more specifically while still giving the abdomen the bulk of the timeframe. When deep work was contraindicated by an acute flare of her symptoms, I still spent a long time working within her comfort on the abdomen, using gentle Swedish strokes, superficial myofascial work, and tracing the colon stroke lightly. As we got into the rhythm of weekly sessions and she experienced a whole month without flares, the work developed a sense of continuity and productivity. The colon stroke, she shared, was particularly effective for her.
To mark and celebrate our final session, I invited Rose to light a candle during our final intake. I gave her a full body Swedish massage with a slightly shorter abdominal focus, then took a little extra time after the massage to ask her about her experience overall. At the end of our conversation, I thanked her for her help in my learning and invited her to extinguish the candle. I like that though there is an ending implied in blowing out a candle, it doesn’t at all prevent it from being lit again. I don’t know if she necessarily saw the symbolism that I did, but she certainly had fun doing it, reminding me that we often blow out candles as part of celebrations as well!
What changed?
Results
Rose self-reported her symptoms with the Patient-Reported Outcomes Measurement Information System (PROMIS)6 before and after our time together. I scored them according to their published rubrics7 and summarized the outcomes in the following diagram. Overall, her symptoms decreased in measured severity.
Because this is a chronic condition with periods of flare and remission, change in symptom severity is expected to fluctuate and it is unclear if these are significant changes. If they are, they cannot be conclusively indicated as a permanent improvement or attributed to massage without a higher power study. However, from the perspective of the client, these changes are encouraging and undoubtedly welcomed.
A free agent
Conclusions
It is interesting to me that Rose’s measured symptoms decreased in severity, but I am more excited about how her relationship with her condition changed. Initially, Rose was not confident in describing her symptoms. She often told me about a symptom after it had resolved, she had not noticed it until it changed. She identified bloody stool as proof that she had been having a flare but was unsure until then if her symptoms were a result of her ulcerative colitis or an indulgent lunch. As our work progressed, she began to notice her symptoms more, and then to link them to the presence or absence of bloody stool. Eventually, she noticed patterns and qualitative differences in the symptoms that led to bloody stool and those that did not. In our sessions, she began to say more confidently that she was or was not having a flare. She is still exploring what helps, but as she is more aware of her body and reactions, she can better evaluate what she tries. This increased somatic understanding is helpful not only in managing symptoms appropriately but in fostering agency in self-care.
Of course, increased self-awareness and resulting confidence could have been achieved by the client in many ways- on her own, with the help of a counselor, in a group environment, or through any practice that helps increase mindfulness. Though massage is just one such option, does have a unique appeal. Massage provides an extended period of time to be with one’s body which is especially approachable to those new to practicing present mindfulness. Where an hour of seated meditation may feel boring or isolated, relationship and stimulation are present in massage. Simply meditating can be a purely mental experience- massage constantly reminds the receiver of their body through touch. When awareness of the body is unappealing due to pain, lessening of the pain through soft tissue manipulation is encouraging. Unlike yoga or an exercise routine, receiving massage requires comparatively little client effort and so is less likely to be avoided.
In a pathology where prevention of acute flares is so important to quality of life, practicing this kind of self-awareness is key to identifying patterns and properly managing symptoms. Although it is unclear how much of Rose’s symptomatic change may have been due to massage, she used these sessions to facilitate her own body awareness and demonstrated increased confidence in managing her recently diagnosed ulcerative colitis. This case illustrates the successful incorporation of massage as self-care and a tool of empowerment in managing a chronic digestive disorder.
Appendix
| Symptom | PROMIS Form | Initial T score | 9/14/18 | Final T score | 12/8/18 | Difference |
| Diarrhea | Diarrhea (6a) | 56.1 | Mild | 39.9 | Normal | 16.2 |
| Belly Pain | Belly Pain (5a) | 58.4 | Mild | 48.3 | Normal | 10.1 |
| Constipation | Constipation (9a) | 61.3 | Moderate | 63.7 | Moderate | -2.4 |
| Nausea | Nausea (4a) | 71.6 | Severe | 62.8 | Moderate | 8.8 |
| Bloating | Gas and Bloating (13a) | 60.2 | Moderate | 43.8 | Normal | 16.4 |
| Reflux | Gastroesophageal Reflux (13a) | 58.6 | Mild | 47.1 | Normal | 11.5 |
| Disrupted swallowing | Disrupted swallowing (7a) | 49 | Normal | 40.3 | Normal | 8.7 |
| Fatigue | Fatigue (short form 13a) | 63.2 | Moderate | 52.5 | Mild | 10.7 |
| General well being | Global (PROMIS-29 v2.1) | 73 | Excellent | 83 | Excellent | 10 |
Endnotes
- Note: Name changed for privacy
- Ulcerative Colitis. (2014, September 01). Retrieved from https://www.niddk.nih.gov/health-information/digestive-diseases/ulcerative-colitis
- Massage and Bodywork Magazine for the Visually Impaired – When Food Hurts. Retrieved from https://www.abmp.com/textonlymags/article.php?article=1297
- Pathology and Massage. Retrieved from https://www.worldmassageconference.com/sites/default/files/RuthWerner-PathologyandMassage.pdf
- Definition and History. Retrieved from https://www.arvigotherapy.com/content/definition-and-history
- Health measures. Retrieved from http://www.healthmeasures.net/index.php
- “Score Ranges.” Health Measures, www.healthmeasures.net/score-and-interpret/interpret-scores/promis.
