Summary
Hypertension is considered to be a condition that requires treatment adaptation and/or medical consultation. Hypertension is defined by the Merck Manual as the "sustained elevation of resting systolic BP (≥ 140 mm Hg), diastolic BP (≥ 90 mm Hg), or both (MercksManualOnlineMedicalLibrary, 2007). Ninety-two percent of people with hypertension have "primary" hypertension, which has no identifiable cause. 3-5% of people with hypertension have "secondary" hypertention, in which a specific gene or diseased organ is the cause (MMOML, 2007). The risk factors for hypertension include diabetes mellitus, family history of cardiovascular disease, high cholesterol, obesity, smoking, alcohol intake, salt intake, and stress (HeartCanada, 2001).

The dangers that massage therapy may place on a person with hypertension involve the application of heat and/or deeper, painful pressure (especially to the torso), and treatment position. There have been studies that suggest that exposure to prolonged heat and/or high temperatures may affect a person with hypertension more so than someone of a normal blood pressure. Studies such as (Gaebelein, Senay, & Ladd, 1985) and (Malo, Tremblay, & Hamet, 1988) suggest that this thermosensitiviy may be caused by a genetic defect in hypertensive people that produces an abnormal stress response to heat (Malo, et al, 1988). Although there are a great number of studies that show that moderate to light massage causes a decrease in blood pressure, it has been seen that deeper, more painful massage techniques such as trigger point therapy and sports massage may increase systolic and diastolic blood pressure (Aourell, Skoog, & Carleson, 2005) (Cambron, Dexheimer, & Coe, 2006). It also seems that applying moderate pressure to the lower torso in prone position can lead to significant cardiovascular change, particularly to the inferior vena cava (Krauskopf, Mayerhoefer, Oberndorfer, Salameh, Bur, & Risser, 2008). The prone position, itself, has actually been noted to reduce venous return to the heart (Toyota & Anaki, 1998)(Dharmavaram, Jellish, Nockels, Shea, Mehmood, Ghanayem, Kleinman, & Jacobs, 2006). This is caused by an increase in intrathoracic pressure due to the nature of the position. Compared to both the prone and supine positions, it seems that the side-lying position may be the most beneficial position, hemodynamically, as it has been shown to increase stroke volume and left ventricular contractibility (Siepe, Ruegg, Giraud, Python, Carrel, & Tevaearai, 2005).

Before beginning any treatment with a patient that has known hypertension and/or is exhibiting symptoms of it (see list of "Red Flags"), it is important that they first consult with a physician to bring the blood pressure under control. As massage therapists, we can alter our hydrotherapy and massage treatments to accommodate people with controlled hypertension. Most literature agree that if people with hypertension are to be exposed to heat, it should be of short duration and lowered temperature (Press, 1991). Also, It is reasonable to assume that it is safer to only use lighter, non-painful massage techniques and to use only lighter pressure to the torso while in prone position. Positionally, side-lying is preferred for a patient with hypertension as it seems to be the most beneficial for blood flow to and from the heart.

keyword list
hypertension
high blood pressure
AND
hyperthermia
thermosensitivity
hot tub(s)
sauna(s)
hot bath(s)
prone (position)
supine (position)
side lying (position)

prevalence of condition
92-94% of people with HT have primary HT (no identifiable cause)
3-5% have secondary HT (a specific gene or organ, such as kidney, are responsible)
Risk Factors: diabetes mellitus, family history of cardiovascular disease, high cholesterol, obesity, smoking, alcohol intake, salt intake, stress (1)

relevant literature

1. http://www.heartcanada.com/hypertension.php

2. Aourell, M., Skoog, M., & Carleson, J. (2005, November). Effects of Swedish massage on blood pressure. Complementary Therapies in Clinical Practice, 11 (4), 242-6.



3. Cambron, DC, MPH, PhD, JA, Dexheimer, LMT, J., & Coe, DC, CMT, P. (2006, January-February). Changes in blood pressure after various forms of therapeutic massage- a preliminary study. Journal of Alternative and Complementary Medicine, 12(1), 65-70.



4. Barr, JS & Taslitz, N. (1970, December). The influence of back massage on autonomic function. Physical Therapy, 50 (12), 1679-91.



5. Kaye, AD, Kaye, AJ, Swinford, J., Baluch, A., Bawcom, BA, Lambert, TJ, & Hoover, JM (2008, March). The Effect of Deep-Tissue Massage Therapy on Blood Pressure and Heart Rate . Journal of Alternative Complimentary Medicine, 14(2), 125-8.



6. Reed, BV., & Held, JM. (1988, August). Effects of sequential connective tissue massage on autonomic nervous system of middle-aged and elderly adults, Physical Therapy, 68 (8), 1231-4.



7. Bauer, WC, & Dracup, KA (1987, December). Physiologic effects of back massage in patients with acute myocardial infarction. Focus on Critical Car,e 14 (6), 42-6.



8. Plaugher, G., Long, CR., Alcantara, J., Silveus, AD., Wood, H., Lotun, K., Menke, JM., Meeker, WC., & Rowe, SH. (2002, May). Practice-based randomized controlled-comparison Clinical Trial of Chiropractic Adjustments and Brief Massage Treatment at Sites of Subluxation in Subjects With Essential Hypertension: Pilot Study. Journal of Manipulative & Physiological Therapeutics, 25 (4), 221-39.



9. Dunbar, S., & Redick, E. (1986, June). Should patients with acute myocardial infarctions receive back massage? Focus on Critical Care, 13 (3), 42-6.



10. Siewert, H., Strangfeld, D., Scherf, HP., Meffert, H., Winterfeld, HJ., & Dittmann, K. (1989). Hemodynamics of Patients with Essential Hypertension in Mild Infrared Hyperthermia. Dermatologische Monatsschrift, 175 (12), 741-4.



11. Shin, TW., Wilson, M., Wilson, TW. (2003, December 9). Are hot tubs safe for people with treated hypertension? Canadian Medical Association Journal, 168 (12), 1265-8.



12. Gaebelein, CJ., Senay, LC Jr., & Ladd, CM (1985). Changes in blood pressure, heart rate and blood constituents during heat exposure in men with elevated blood pressure. European Journal of Applied Physiology & Occupational Physiology, 54 (5), 506-10.



13. Malo, D., Tremblay, J., & Hamet, P. (1988, December). Genetic and molecular characteristics of thermosensitivity in hypertension. Journal of Hypertension-Supplement, 6 (4), S55-7.



14. McMurtry, JP, & Wexler, BC (1983, January). Hypersensitivity of spontaneously hypertensive rats to heat and ether before the onset of high blood pressure. Endocrinology, 112 (1), 166-71.



15. Sorokina, EI, Iachmenev, NV, & Goncharova, OI (1994, September-October). The effect of contrast baths on physical work capacity and autonomic regulation in hypertension patients. Vaprosy Kurortologii, Fizioterapii I Lechebnoi Fizicheskoi Kultury, (5), 4-7.



16. Press, E. (1991, August). The health hazards of saunas and spas and how to minimize them. American Journal of Public Health, 81 (8), 1034-7.



17. Merck Manual Online Medical Library



18. Krauskopf, A., Mayerhoefer, M., Oberndorfer, F., Salameh, B., Bur, A., Schneider, B., & Risser, D. (2008, June). Does weight force application to the lower torso have an influence on inferior vena cava and cardiovascular parameters? American Journal of Emergency Medicine, 26 (5), 603-7.



19. Siepe, M., Ruegg, DM, Giraud, MN, Python, J., Carrel, T., Tevaearai, HT (2005, July). Effect of acute body poisitonal changes on the haemodynamics of rats with and without myocardial infarction. Experimental Physiology, 90 (4), 627-34.



when and why it is dangerous to work on a patient with that condition

Deeper, more painful massage techniques such as trigger point therapy and sports massage may increase systolic and diastolic blood pressure.

Heat may be a higher stressor for people with hypertension and there may be a genetic component involved. This should be taken into account, when administering hydrotherapy to people with high blood pressure. Shortening time exposure to and lowering temperature of the heat has been suggested.

the signs and symptoms to watch for (red flags)
dizziness
drowsiness
confusion
headache
nausea
loss of vision

references to research that support the reasons why this condition is a CI

“Trigger point therapy and sports massage both increased the systolic BP, and if both forms of massage were included in a session, both the systolic and diastolic BP readings significantly increased (Cambron, Dexheimer & Coe, 2006) ”


“...various studies have found conflicting evidence as to whether massage can produce a relaxation response and thus the decrease in BP (Cambron, et al, 2006).”

“...results of this study demonstrate that the change in BP may be based on massage type, with certain forms of massage actually increasing the systolic BP. The most significant increase in BP within this study was through trigger point therapy, which may cause a pain response and thus an increase in sympathetic nerve activity and an increase in BP (Cambron, et al, 2006).”

“Future studies on BP changes in massage may include a survey question on pain felt during the massage in order to determine if this is the factor associated with BP increase (Cambron, et al, 2006).”

“These data demonstrate that certain forms of massage (particularly those forms that may cause pain) may increase the client’s BP rather than decrease it (Cambron, et al, 2006).”

“A case series of 150 massage therapy clients was completed to determine change in BP and factors associated with this change. It was determined that certain types of massage were significantly associated with an increasein systolic BP, such as trigger point therapy and sports massage; and that there appeared to be a decrease in systolic BP with Swedish massage, although this result was not statistically significant. Likewise, a combination of trigger point therapy and sports massage was associated with an increase in systolic as well as diastolic BP. No significant association was noted between change in BP and body area massaged, duration, or pressure used during massage (Cambron, et al, 2006).”

“We defined the type of massage used in the study as follows: Swedish massage is considered the most “traditional” form of massage and uses compression, holding, gliding (effleurage), kneading (petrissage), shaking, tapping, and friction. Deep tissue massage is designed to reach the deep layers of muscle and uses a combination of compression, cross-fiber, and friction strokes. Myofascial release is a technique in which the fascia connecting and surrounding muscle is manipulated by the therapist. Sports massage is typically a more vigorous type of massage used to prepare athletes for peak performance and uses a combination of techniques including joint mobilization, stretching and/or postisometric relaxation, cross-fiber friction, and pressure point massage. Trigger point massage is a neuromuscular technique used to break the pain-spasm-pain cycle and uses focused ischemic pressure at sites of myofascial trigger points. Finally, craniosacral massage uses gentle touch on the head and sacral areas to release restrictions. Details about the massage were collected from each therapist after each client’s massage (Cambron, et al, 2006).”

“...LAF (leg, arm, and face) massage (P<0.05) increased systolic blood pressure (Aourell, Skoog & Carleson, 2005).”

"Within 30 min systolic, diastolic and mean BP of the high BP subjects had decreased to normal levels; no BP changes were detected in normotensive subjects. Accompanying this depressor response was an exaggerated elevation in plasma glucose concentration. Data suggest that heat exposure may have been more stressful for the subjects with high BP than for their controls. This finding implies that phasic depressor responses may be as important as phasic pressor episodes in the aetiology of established essential hypertension (Gaebelein, Senay & Ladd, 1985)."

"Our results indicate that thermosensitivity is genetically linked with hypertension and characterized by an abnormality in the synthesis of stress proteins as well as in the expression of their mRNA following heat exposure, which implies that a genetic defect is present in response to environmental stress in spontaneous hypertension (Malo, Tremblay & Hamet ,1988)."

"Recommended preventive measures include shortening the time of exposure, lowering the temperature,...(Press, 1991)

"Hypertension is sustained elevation of resting systolic BP ( 140 mm Hg), diastolic BP ( 90 mm Hg), or both. Hypertension with no known cause (primary; formerly, essential hypertension) is most common. Hypertension with an identified cause (secondary hypertension) is usually due to a renal disorder (MMOML, 2007)."

"Application of moderate weight force to the lower torso can lead to major changes in Inferior Vena Cava parameters and minor changes in cardiovascular parameters (Krauskopf, Mayerhoefer, Oberndorfer, Salameh, Bur, Schneider & Risser, 2008)."


"In humans, the lateral recumbent position has a beneficial effect on haemodynamics (
Siepe, Ruegg, Giraud, Python, Carrel, Tevaearai, 2005)."