Touch and caring are often inseparable.
--Gloria Joachim
This is a sort of review of an article, where I engage with it, and in the process share my experiences in the clinic, both as a practitioner, and as a patient in the hospital for a month, recovering from a blood clot, surgery, and complications.
Even more important, I summarize the important practical points for your application in massage, and as massage skills are so foundational to our field, I'm including the ability to give a great foot massage as a foundational concept.
Gloria Joachim, a family nurse practitioner who was an assistant professor at the School of Nursing, University of British Columbia, Vancouver, at the time she wrote this article, and who is now emerita there, published this article in 1983 as a guide for nurses in how to provide effective foot massages for their patients. Although cutting-edge research articles go out of date very quickly, articles about tried-and-true techniques, such as the ones Joachim discusses, are timeless.
Some of the information will be out of our scope of practice as MTs; I'll indicate when that is the case.
Massage claims in the Joachim article
More than just a component of complete care, foot massage has physiological and psychological benefits for the whole person.
--Gloria Joachim
Joachim makes the following claims in her article about the benefits of massage:
-
While massaging, the nurse can
-
assess the feet,
-
stimulate circulation,
-
decrease edema, and
-
provide a local form of passive exercise.
-
As the feet and body relax, heart and respiratory rates decrease.
Except for the "stimulate circulation" claim, which is a little vague, these claims are fairly well-supported by the evidence, and none of them is particularly controversial.
Joachim finds that the the therapeutic relationship between the nurse and patient is enhanced when the patient is relaxed, because they are both more self-expressive (which lets the nurse know what's going on with them), and more open to health education and good information from the nurse. The example she provides is educating a client with regard to a diagnostic test or special diet, considerations that are outside our scope of practice, unless we have additional training in a field that permits us to counsel clients about those topics, as recognized by the regulatory authorities in the region we're practicing in.
What Joachim does not state, but what I found from my own experience as a patient in the hospital, is that the massage also helped me cope with the fear, anxiety, and loneliness that accompanied that month-long stay. There is a fairly solid body of literature for anxiety, and the effect of massage on fear and loneliness in long-term hospital patients could probably be studied in the same way.
Recommendations for timing of foot massage
She finds that before the patient has hospital procedures done (where procedures mean such things as surgery, imaging, and other specialized protocols), as well as bedtime, are excellent times for the nurse to perform massage for the patient to promote relaxation.
She states that:
On these occasions a foot massage can decrease the need for pain and sleeping medications.
which are two good hypotheses for further study, and for both of which there is some existing literature already that tends to support it, although that literature is not especially strong. These would be most worthwhile to study further.
Recommendations for sequencing of foot massage
Joachim recommends that massage follow complete foot care, although depending on the nurse's intention, there may be reasons to do the sequence differently.
Here are a couple of questions for the spa practitioners out there: although nursing foot care is different from spa foot care, there is a certain amount of overlap as well.
-
Is there a standard sequencing for massage and other foot care? Does massage precede foot care, or follow it, or does that simply depend on spa personnel scheduling, rather than sequencing considerations?
-
How much evaluation is given to the clients' feet before spa foot care is carried out? Are there any warning signs of problems that spa personnel are trained to look for, and alert the client to, if found?
Joachim recommends that before the massage, you (here, she means a nurse, but this is valid for MTs as well) examine the feet for:
-
swelling,
-
color,
-
ulcerations,
-
areas indicating pressure,
-
toe deformities,
-
cleanliness,
-
odor, and
-
condition of the nails and skin.
She takes for granted here that her audience of nurses knows what signs to look for and what to do if they are found; specifying them for reference for MTs would be a very valuable POEM sub-project, and I'm putting it on the to-do list.
Contraindications for massage
She advises that the presence of any of the following conditions are contraindications for foot massage:
-
skin lesions,
-
blood clots,
-
fractures,
-
or extreme arthritic pain.
This is not an exhaustive list, but they are the ones she mentions.
Pre-massage foot care
Joachim recommends using warm water to clean and soak the feet before beginning the massage. While this is not specifically out of scope for an MT, it's not the usual practice outside of a spa, and it may not be common practice in most spas, apart from other foot care, either.
Remember that Joachim is working with ill patients in a hospital, rather than healthy young clients who are going to get up from the table after you are finished massaging.
It's easier and less complicated for an MT to skip this part of Joachim's routine. If you did decide you wanted to offer this as a service as part of your massage, it's vitally important that you are clear on both of the following points:
-
Make sure that your massage area and your practices protect your patient against slipping on the floor.
-
Make sure to dry the foot surfaces and in between the toes well and thoroughly to protect against fungal infection.
-
Make sure that anything you offer in the way of washing or cleaning your client's feet fall squarely within your scope of practice in the regulations governing the area or region in which you practice.
NEVER:
-
Offer to trim the client's toenails, unless you are specifically trained in another field, such as beautician or nurse, and you are practicing as a member of that field. MTs do not have the specific knowledge and training to safely cut toenails for members of the public, especially in conditions that may be found in ill or elderly clients. Joachim's advice on nail-trimming is meant for nurses, and is totally out of scope for us MTs.
Positioning for foot massage
Joachim instructs the nurse to help the patient find a comfortable position, usually lying supine in bed. She advises putting a small pillow under the patient's knees to create a pelvic tilt, a standard technique taught in massage schools. She also recommends a pillow under the head, as her patients usually are in a hospital bed rather than a massage table.
She advises standing at the foot of the bed, although the patient may want to sit, and in that case, sitting and supporting the foot on your knees is a good position for foot massage.
Preparation for foot massage
In my experience, the warning not to touch a client with cold hands is widely taught in massage school, and Joachim advises washing your hands with warm water before touching. This is good advice if you have access to a sink; if you don't, you can also rub your hands together briskly, although that method seems to be less effective.
Joachim recommends centering as a way to promote your ability to pay attention to your client. She describes the technique of centering in this way:
Take a moment to achieve a calm feeling and block out external problems; this is called centering. This necessary step enables you to give your full attention to the patient and to the work of massage.
She stresses the need to be attentive to feedback from the patient during massage about what feels good and what doesn't. In my experience, this checking-in and watching for verbal and other bodily cues is taught fairly standardly in massage schools.
Her advice not to initiate a great deal of conversation with the patient during massage, but to be prepared to respond appropriately if a patient gains any benefit from talking, is also consistent with what MTs learn in school.
She recommends rubbing lotion or baby oil as a massage lubricant between your palms, and holding one foot
gently but firmly to let the patient feel your presence before you begin.
Foot massage sequence
-
Hold the foot in both hands; Joachim advises "gentle but firm" pressure.
(image posted provisionally while obtaining permissions)
-
Make thumb circles over the entire sole of the foot.
(image posted provisionally while obtaining permissions)
-
Use your fingers to spread out and stretch the skin of sole at the ball of the foot.
(image posted provisionally while obtaining permissions)
-
Holding the foot in one hand, use the knuckles of your other hand to stroke the sole up and down the length of the foot.
(image posted provisionally while obtaining permissions)
-
As you did in the previous step, use one hand for support, and work with the other hand.
This time, you'll use the support hand to stabilize the base of each toe in turn, while using the work hand to rotate that toe back and forth.
As a nurse, Joachim uses the opportunity this part ofthe routine provides to look between the toes for signs of any conditions that need to be attended to.
-
Once again, you'll use one hand as a support hand to lift the foot very slightly, enough to get your work hand underneath.
Use the work hand to cradle and knead the heel and ankle between your thumb and forefinger.
You can also use your fingertips to make circles on the heel.
Here, she makes the point that you can and should use greater pressure on the heel, because this skin is very thick. Remember from our study of the skin that the thickest areas, the sole of the foot and the palm of the hand, have an extra layer of skin, the corneum lucidum, that thinner skin elsewhere on the body does not possess.
(image posted provisionally while obtaining permissions)
-
Cradle the foot firmly between both hands for a moment before repeating this sequence on the other side.
(image posted provisionally while obtaining permissions)
Once you've done the massage on one foot, repeat the sequence on the other foot.
Finish the entire foot massage by cradling both feet firmly and quietly before releasing.
In their own words: After the massage
Joachim's description of various ways that patients respond to foot massage contains a great deal of important information:
Following foot massage, patient response varies. Some wish to be left alone to enjoy the relaxed feeling. Some like to walk because "it feels like walking on air." Others, because they feel so cared for and nurtured, want the nurse to stay and be close to them...Having given a foot massage may make the nurse special to the patient and foster invaluable rapport. Using this knowledge therapeutically enables the nurse to meet the patient's needs more fully. For example, an anxious or suspicious man may now trust his special nurse to know that he fears he may never be well again.
She's correct about the power of massage to foster rapport, but a nurse is better trained than we are to handle what can come out of that connection. In my experience, some MTs report that they have received enough training to teach them how to deal with transference, while others report that they haven't had the training they need to cope with situations that have arisen in their practices.
The massage field needs to promote education around these issues, given the power of this connection that Joachim describes.
I've actually experienced how she decribes, in understatement, that massage is "much appreciated" by patients. I've told this story here before, and you can find the original post by clicking on this link.
In 2002, I had a blood clot in my superior mesenteric artery that caused 3 feet of my small intestine to die, requiring emergency resection. Due to complications, including developing fluid around my lungs, I spent almost an entire month in the hospital.
It's hard to describe what it feels like to come so close to death, and then to have to work my way back slowly away from the edge of the cliff. "Alone", "frightened", "vulnerable"--these certainly all were part of it, but they're insufficient to depict the experience. My family, friends, and graduate program were wonderfully supportive, but no matter how much they were there for me, there are some things you just have to go through alone.
While I was in the hospital, I was moved to a floor that had a volunteer MT come in once a week to offer patients a massage. I remember it was Wednesdays when she made her rounds.
The first Wednesday, she came around and offered a free hand and foot massage, which I gratefully accepted. It's not that I was touch-deprived, not exactly--but the touch I was getting in the hospital was almost universally invasive touch--blood draws, infusions of dye for CAT scans, IVs for feeding and painkillers. Although there was lots of touching, I was definitely "good touch"-deprived. Her simple offering of a hand and foot rub turned into one of the best experiences in my life.
The next Wednesday, she returned, and once again, it was the high point in a week that had very few other good experiences.
The next Wednesday, I waited eagerly, my anticipation heightening from minute to minute for another of the massages I had grown to love. When it finally dawned on me that she wasn't coming this time, I cried and cried inconsolably.
Let me be 100% absolutely clear on this point--she did nothing wrong. She had not promised me that she would be back the next Wednesday; she did not stand me up. I am not reproaching her for anything she did at all.
It was only in my own head that we had an appointment that day. I had become used to her coming around on Wednesdays, and--because there was so little else good in my immediate daily life at that point--I had grown dependent on her being there for massage.
She did absolutely nothing wrong at all--but because I remember how absolutely crushed I felt when she wasn't there that last Wednesday, I've begun taking extra steps in the clinic to make sure that--in addition to doing nothing wrong--I actively do something right.
The point of that story is that I grew to need and depend on a simple hand and foot massage so much that I am very careful about letting hospital clients/patients, with no specific massage appointments, know whether to expect me from week to week. That crushing disappointment I felt is how valuable and meaningful that gesture had become to me, as I lay in that bed.
The paradox of what she calls the "essential nonessential function" of massage is just that value and meaning. Although it's not a life-saving measure in the strict sense of "essential function", never underestimate how much you have to offer to clients and patients through the simple and straightforward act of providing a great foot massage.
