Cold Hands, Warm Heart?

Raynaud's Syndrome

By Ruth Werner
[Pathology Perspectives]

Do you want to build a snowman? Think about going outside to play in winter. As you pack that first snowball (glove-free, of course, so you can really feel it), your fingers turn pale, and your hands become numb and a bit clumsy. There’s a good reason for this: your body is, very appropriately, directing blood away from your extremities and into your core. We see it in our face, too: we go pale as our blood is shunted inward. But after a while, we turn pink with new capillary dilation—this happens as the body tries to ensure the survival of our vulnerable superficial cells. It’s a dynamic process that constantly weighs the risk of damage to superficial tissues and the priorities of keeping our organs warm.
But what happens if that complicated response system is impaired? What if the initial vasoconstriction is so severe that some fingers turn starkly white, and then blue—the cyanosis marking the severe oxygen deprivation that is occurring—and then bright red, as the tiny blood vessels open up again and allow blood flow to return? This parade of white, to blue, to red skin—that is accompanied by variations of numbness and pain—is not a patriotic display. It is a sign of a condition called Raynaud’s syndrome: a common, often inconvenient, and sometimes downright dangerous condition.

Raynaud’s Syndrome
Raynaud’s syndrome is surprisingly common: experts suggest it affects 5–10 percent of the population. Women have it more often than men, and it is most common among people in their 20s and 30s. Not everyone is sidelined by this condition, however, and it occurs on a broad continuum of severity. Someone with a mild case may never need medical treatment, but someone at the opposite end of the spectrum is at risk for losing a digit, or worse. And because about one out of every 20 people has occasional symptoms, the chances of it becoming an issue for massage therapists are fairly high.

What Happens?
To understand a little more about this condition, we need to revisit some cardiovascular system anatomy.
We all remember that arteries carry blood away from the heart, and veins carry blood toward the heart. We might also remember that the aorta is the biggest artery in the systemic circuit, and it divides and subdivides again and again into smaller arteries. Tiny arteries are called arterioles, and most arterioles then turn into capillaries with walls made of delicate endothelium—just a single cell thick. This is where the oxygen/carbon dioxide exchange happens, along with nutrient/waste exchange, by way of interstitial fluid. Capillaries then get bigger and slightly more complex in construction and become venules; venules converge into veins, and all the veins eventually feed back into the largest vein, the vena cava.
In some areas, however, the arterioles and venules do not telescope down into capillaries; instead, they connect directly to each other. These sites are called arterio-venous anastomoses. They influence nearby circulation, and they are vulnerable to the extreme reactions to cold and/or stress that we see with Raynaud’s syndrome.

“My cardiologist said he believes—and it’s rare apparently—that my heart attack was caused by Raynaud’s: it affects the same kinds of arterioles that were involved in my heart attack.”
—Choice Kitchen, massage therapist and person with scleroderma and secondary Raynaud’s phenomenon.

Two Kinds of Raynaud’s Syndrome
The first person to document this condition (and get the credit for it) was a French medical student named Maurice Raynaud in 1862. He proposed, and it was widely accepted, that this disorder is caused by extreme vasospasm in reaction to exposure to cold or stress. Since then, we have found that this condition occurs in two ways: as a freestanding disorder or as a complication of some other problem or situation.

Raynaud’s Disease: A Freestanding Condition
The most common form of Raynaud’s is also the less extreme, with the lowest risk of serious complications or tissue damage. This is Raynaud’s disease. It develops independently of other conditions. Raynaud’s disease is idiopathic: of unknown origin. It is a functional problem with vasoconstriction, but it doesn’t lead to any structural changes in capillaries, and this is an important feature that helps to distinguish it from the other form of Raynaud’s.

Raynaud’s Phenomenon: Caused by Something Else
Raynaud’s phenomenon occurs as a complication of some underlying disease or condition that impacts vasodilation and constriction. Contributing factors include autoimmune diseases, chemical exposures, mechanical issues, or other factors.
Autoimmune diseases. There are several autoimmune diseases that can contribute to Raynaud’s phenomenon. Scleroderma often has this component. (For more on the relationship between Raynaud’s phenomenon and scleroderma, read “Crest Syndrome” in the November/December 2009 issue of Massage & Bodywork, page 106.) Other autoimmune diseases associated with the development of Raynaud’s phenomenon include lupus, rheumatoid arthritis, and Sjögren’s Syndrome.
Chemical exposure. Nicotine is a powerful vasoconstrictor, and people who smoke are more prone to serious attacks of Raynaud’s phenomenon than nonsmokers. Vinyl chloride, a chemical used in the plastics industry, is associated with this risk, as are several medications that change blood vessel function, including ergotamine (used for migraines), beta-blockers (used for hypertension), some cancer treatments, some over-the-counter cold and allergy medications, and birth control pills.
Mechanical factors. The blood vessels in the extremities may be healthy, but if a person has other environmental factors or exposures that interfere in their function, they may lose the ability to respond appropriately to changes in ambient temperature. Using heavy or vibrating equipment (jackhammers, drills, belt sanders), doing repetitive tasks with the hands, or having some obstruction to blood or nerve flow (like carpal tunnel syndrome) can all lead to Raynaud’s phenomenon.
Other factors. A history of trauma to the extremities may be another contributor to problems with vasomotor responses. If a person has ever had frostbite or surgery to the hands or feet, the risk of Raynaud’s goes up. A handful of other situations may also contribute to the risk of Raynaud’s phenomenon, including some blood disorders, thyroid problems, and pulmonary hypertension.

Raynaud’s phenomenon is usually much more severe than primary Raynaud’s disease, and it carries a risk for structural changes that can lead to severe damage in the skin on the extremities, including ulcerations and the possibility of gangrene. It usually affects the fingers, but it could also involve the toes or ears. Some of the early structural changes can involve capillary deformation at the nail beds. This is easily observable with simple laboratory tests, and it is an early indicator of Raynaud’s phenomenon.
In addition to deformed capillaries in the fingertips, new technology shows that people with Raynaud’s phenomenon show three interesting variances from the norm: they have a deficiency of local vasodilators (so vasoconstriction is unopposed and extreme); they may have some abnormal brain stem function that fails to integrate cardiovascular responses with stress—this also leads to impaired dilation and enhanced constriction; and they show unusually high levels of platelet activation. These discoveries may seem abstract, but they could lead to new strategies for treatment, so they could be important for people who struggle with this condition.

Signs and Symptoms
We have already discussed the prevailing signs and symptoms of Raynaud’s syndrome. A typical episode begins with a sudden onset of extreme vasoconstriction, usually in parts of the fingers or toes. Triggers may be exposure to cold temperatures, or stress, or both. The vasoconstriction is so severe that the skin may develop patches of grey or white, and then a bluish tone takes over—this is cyanosis, literally “condition of blueness”—as the cells are starved of oxygen. When the vasoconstriction releases, it is often followed by extreme vasodilation and a bright red flush over the previously blue areas.
The main symptoms of Raynaud’s syndrome have to do with color change and the sensation of cold; but tingling, throbbing, numbness, and burning pain are often also part of the picture. Raynaud’s syndrome episodes can last anywhere from a minute or two to several hours, and they happen with unpredictable frequency.

Treatment Options
People who are susceptible to Raynaud’s know to take special care of their temperature zones—they are advised to be well prepared with gloves or mittens and good socks, and to wear hats and wrap their trunk and neck well in cold temperatures. Many patients keep gloves next to the freezer for when they have to retrieve a bag of frozen peas or a package of hamburger to defrost for dinner. And if they are smokers, they are advised to quit or cut down as much as possible.
If these self-care options are insufficient, and if a move to a warmer climate is not realistic, then a person with Raynaud’s phenomenon may have to consider pharmacological intervention. This could include some vasodilators like calcium channel blockers or alpha blockers, or it could mean using prescription skin cream with counterirritants that promote vasodilation on the surface. In the most extreme cases, doctors may try to block the motor nerves that control vasoconstriction in the affected area. This can be helpful, but it is typically a temporary solution that may need to be repeated as the damaged nerves recover.
All of these options have implications for massage therapy, so it is important to be aware of how a person with Raynaud’s syndrome manages their condition.

Implications for Massage
Both forms of Raynaud’s syndrome involve vasospasm in response to cold or stress. As long as the skin is healthy and intact, massage for this condition is not only safe, it is probably a really good idea—both for stress reduction and for localized blood flow.
To my knowledge, no research about massage for Raynaud’s syndrome has been published, but scads of anecdotes support this idea, including what massage therapist Choice Kitchen does for his own hands: “My best treatment for the hands, when they’re cold or when they’re throbbing or achy (most all the time) or after a hard day, is my hot water treatment. I turn on the kitchen faucet water to pretty warm. When my hands are acclimated, I turn the water a little hotter. Usually by the third increase, I start wringing my hands like a cloth, paying particular attention to the fingers, wringing, massaging, and stretching each one. When it gets too hot, I quit. By then, my hands are usually pink, and they feel oh-so-good.”
Another helpful suggestion comes from a practitioner from South Carolina: “One of my clients with Raynaud’s syndrome was a smoker. She got some cramping during her massage, so we agreed that she would not smoke for a few hours before her appointment to limit the vasoconstrictor properties of nicotine.”    
He adds that it is important to make sure the client doesn’t have to go through any sudden decreases in heat: keeping a warm room and a warm massage table and preparing a gentle transition back to the outside world are all important.
Ultimately, the choices about massage therapy for a person with either type of Raynaud’s syndrome boil down to this: What are the risks? What are the benefits? Can I design a session that eradicates the risks while maximizing the benefits?
The risks include the possibility of weakened or damaged skin with Raynaud’s phenomenon, plus making appropriate accommodations for underlying factors and medication. We also need to be mindful of not asking our clients to make adjustments to sudden drops in temperature.
The benefits of massage include being able to help reduce stress and improve local circulation, especially if we include extra elements like hot stones or a paraffin bath. As long as the skin is intact and healthy, massage therapy looks like a terrific option for a person with Raynaud’s syndrome to consider. But it would be great if a massage therapist could gather some data to share on whether bodywork had any impact on the duration, frequency, or severity of Raynaud’s syndrome episodes—and then share it with the rest of us. Maybe that will be you!

Ruth Werner, BCTMB, is a former massage therapist, a writer, and an NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2016), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.