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Massage Today
February, 2012, Vol. 12, Issue 02

A Massage Protocol for Peripheral Neuropathy

By Rita Woods, LMT

My last article in the October 2011 issue focused on diabetic peripheral neuropathy and I want to stress the importance of reviewing that information before proceeding on to this protocol. This protocol is only successful when you have full client participation and when you understand the clinical significance and importance of this potentially devastating condition.

Under treating or failing to engage the client in their own treatment can render this protocol useless. This is a protocol that requires 100% participation and commitment from the therapist and client.

While my focus has been on diabetic peripheral neuropathy, is important to note that this protocol also works for chemotherapy-induced peripheral neuropathy (CIPN). Some chemotherapy agents cause peripheral neuropathy that is so disturbing and painful to the patient that they consider stopping their chemotherapy treatment. Because that is not a viable option, oncologists will sometimes adapt the chemotherapy treatment in hopes of lessening or preventing the neuropathy.

Let's revisit some pathophysiology of peripheral neuropathy as stated in my first article, "distal circulation is compromised and the blood vessels themselves become occluded beginning with the small capillaries. Unable to supply the surrounding tissue and nerves with nutrients and oxygen the resulting oxidative debt ... causes nerves to malfunction sending signals to the brain of pain, tingling, burning and numbness." And now let's recall one of the chief benefits of massage: increased circulation.

foot massage - Copyright – Stock Photo / Register Mark This peripheral neuropathy massage protocol can be painful to the client so care must be taken to work to the client's tolerance in each session. That being said, however, it's important to bear in mind that the ultimate goal is to gradually increase pressure so that eventually you are working tissue "to the bone." Naturally, this is a process. It may be that in the first few sessions all you can do is touch their feet. Remember, you're looking at a long-term relationship with the client so don't rush as the process can take months, depending on the severity of the neuropathy and the cooperation of your client.


  1. Begin each session by inspecting the feet. You are looking for discoloration such as bluish purple spots, redness, sores, cracks in the skin, fungus on the toenails (not uncommon in immune compromised cancer patients) dark spots (gas gangrene first appears as a tiny dark spot), cold areas or anything else that stands out as abnormal. (Toenail fungus is very contagious so do not work on that area if a fungus is present.) Be sure to look in between the toes and encourage the client to do the same every day. If they cannot reach their feet, have them place in a mirror on the floor to view their feet carefully. Experiment with light pressure while you are inspecting the feet. Chart your observations and include a 1 to 10 pain scale based on the client responses. This should take about two minutes.

  2. Next spend about one minute on each foot with light stroking, light pressure using your whole hand and not just the fingertips. Include plantar and dorsal surfaces and all tissue from the toes to the knee.

  3. Now begin some light compression, again using the whole hand. Spend about one minute on each foot lightly compressing the plantar and dorsal surfaces and all but tissue from the toes to the knee.

  4. Begin light stretching, to the patient's tolerance, by performing a full range of motion on every toe joint, at the base of the toes, and at the ankles. Spend about one minute on each foot.

  5. Next you will focus on digital kneading, to the client's tolerance, using light pressure on each toe from the distal tip to the base of the toe. Work on all toe surfaces, front, back and sides. Spend about three minutes on each foot.

  6. Continue the digital kneading in between the ligaments of the foot working from the toes towards the ankle, knead ball of the foot, the arch and the heel. Spend about three minutes on each foot.

  7. Now repeat the digital kneading of the toes and feet with the ultimate goal of massaging "to the bone." In the beginning, remember to work to the client's tolerance only. In each session, progress as deeply as you can. This process will take up the bulk of the protocol so spend at least 10 minutes on each foot. The severity of the neuropathy and whether or not the client is performing their homework massage will be directly related to how deep you can go and how quickly.

  8. Follow this with medium pressure effleurage for about three minutes on each extremity. Massage from the toes to the ankle, around the ankle and up to the knee.

  9. Next perform a sequence of effleurage, petrissage, effleurage, deep pressure from the ankle to the knee, spending about three minutes on each extremity.

  10. Moving back to the toes, begin a sequence of effleurage, petrissage, effleurage, digital and knuckle kneading, and deep pressure including all toes, plantar and dorsal surfaces, the ankle and the calf to the knee. Spend about three minutes on each extremity.

  11. Finish with whole hand stroking from the toes to the knee of all anterior and posterior surfaces. Spend about one minute on each extremity.

Daily, detailed self-care is essential in order to improve or reverse the tissue damaged caused by peripheral neuropathy. The suggested client homework is as follows: Spend 15 minutes each day on each foot. Lightly massage both feet as deeply as you can without causing pain.

Perform full range of motion exercises at your ankles. A fun way to do this is to "write out" the alphabet using your ankle joints and toes. Grasp each toe at the tip in massage and squeeze as deeply as you can without causing pain. Work the entire toe from the tip to the base on both feet.

Deeply stroke the skin of both feet moving in an upward direction toward your knee. Next squeeze and massage all of the tissue of your feet starting between the toes, include the front and back surfaces of your feet. Squeeze, press and massage the entire foot as deeply as you can without causing pain.

Stroke the skin of both feet from your toes to your knees once again moving in the direction towards the knees. Massage the calves then repeat the range of motion exercises at your ankles.

Whenever possible, throughout the day, take off your shoes and rub your feet on the floor, bend and wiggle your toes, roll a tennis ball under the sole of your bare feet, perform your range of motion exercises and massage her feet deeply.

Sixty-minute massage therapy sessions should be performed by a massage therapist once a week for the duration of the symptoms along with the client "homework" outlined above. Remember that infrequent, non-detailed therapy is ineffective and the main goal is consistent, daily, deep work.

For therapists who are also reflexologists, this protocol can be a nice addition to your service. For anyone interested in learning a detailed reflexology protocol that lends itself well to this peripheral neuropathy work, contact me about for more information. You'll find that combining these two therapies is a formula for success.

Editor's Note: For additional information, see Step-By-Step Massage Therapy Protocols for Common Conditions by Charlotte Michael Versagi with contributions by Rita D. Woods. Published by Lippincott Williams & Wilkins, 2011. To find this book and more on medical protocols, visit

Click here for previous articles by Rita Woods, LMT.


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