“Please list your medications.”
As massage therapists, we ask clients to respond to this request for information on our intake forms — but do we know how to use that information? The use of certain drugs may require adaptation of pressure, techniques, positioning and protocol.
In the U.S. today, according to the Centers for Disease Control & Prevention (CDC), over half of our population has taken one or more prescription medications within the last 30 days.
To ensure client safety, massage therapists should continue to educate ourselves about the medications our clients are taking.
A thorough intake is part of any massage, and becomes even more important when working with aging adults — the fastest-growing U.S. demographic. Adults over 50 are statistically more likely to be taking at least one medication for an ongoing health condition.
While the interaction between massage and medication is not entirely understood, massage therapists need to recognize common medications, examine how they work, and know about side effects.
Some common medications massage therapists may encounter when working with adults over 50 include drugs to control heart disease, manage diabetes, reduce chronic pain and treat depression.
Certain medications’ side effects may mimic musculoskeletal pain; interfere with the perception of sensations, including pain; change the structural integrity of tissue; and in some cases warrant physician referral.
Here I will present several conditions a client might be taking medication to treat; common side effects related to the medication; and considerations for massage therapists.
Cardiovascular disease causes nearly 25% of U.S. deaths each year, making heart attacks the leading cause of death in this country, according to the CDC. With that information, it comes as no surprise that medications to treat and prevent hypertension and high cholesterol are some of the most commonly prescribed for adults, and some of the most likely for you to encounter in your massage practice.
The most common drugs used to treat blood pressure act to decrease the sympathetic response, dilate blood vessels, or increase sodium and water excretion through urination. Five types, listed here by brand name first, you will likely encounter:
ACE inhibitors reduce blood pressure by dilating blood vessels, reducing heart rate and decreasing blood volume. ACE inhibitors are easy to identify due to their common prefix ril. For example, Prinivil, Zestril (lisinopril) and Capoten (captopril).
Angiotensin II receptor blockers (ARBs) promote vasodilation by blocking the action of angiotensin II (a chemical that produces contractions of the muscles surrounding blood vessels). Some common ARBs include Benicar (olmesartan medoxomil), Avapro (irbesarten) and Diovan (valsartan).
Beta blockers inhibit the effects of epinephrine, which allows the heart to beat more slowly, lowering blood pressure. Some common beta blockers include Inderal (propranolol), Tenormin (atenolol), Zebeta (bisoprolol fumarate) and Lopressor (metoprolol).
Calcium channel blockers prevent the movement of calcium into the cells of the heart and blood vessels, act as a vasodilator and slow the heart rate. Common calcium channel blockers include Norvasc (amlodipine besylate), Cleviprex (clevidipine) and Cardizem or Dilacor XR (diltiazem hydrochloride).
Diuretics help the kidneys excrete sodium and water from the body, which in turn relaxes blood vessels and lowers blood pressure. Common diuretics prescribed to affect blood pressure include Midamor (amiloride), Aldactone (spironolactone), and Dyrenium (triamterene).
Medications’ Side Effects
The most common side effects for all of these blood pressure medications include hypotension, dizziness, fatigue and nausea. These symptoms might be intensified by the parasympathetic effects of massage.
If the senior massage client feels dizzy after the session, it is recommended that the therapist help him sit up. The therapist should advise the client to get up slowly and stay with him until he feels comfortable.
Another side effect of concern includes coughing. According to the 2013 Nursing Drug Handbook, some ACE inhibitors may interact with capsaicin, a common ingredient in many sore-muscle creams and ointments, exacerbating cough.
If a client has a persistent cough, using a semi-reclined position can help alleviate discomfort. Other side effects, including low-back and leg pain, have been reported. It is important for massage therapists to recognize when pain is associated with medication; while massage might not hurt, it may not provide any long-term relief for the client.
Cholesterol-lowering medications or antilipidemic drugs, especially statins, are also common with the aging population. According to the CDC, 16% of women and 18% of men ages 45 to 64 currently take a statin drug.
That figure jumps to 36% of women and 50% of men ages 65 to 75 years. Common statins are Lipitor (atorvastatin), Zocor (simvastatin) and Crestor (rosuvastatin). Side effects may include headaches, insomnia, edema, abdominal pain, nausea, arthritis and muscular pain.
For massage therapists, the muscular pain reported by clients can be confusing, because it is one of the most frequently described side effects, and the client may have no idea it is being caused by her medication.
There is no evidence that massage techniques need to be altered in most cases; however, if a senior massage client reports any severe pain or weakness, the client should be referred to her physician due to the possibility of a less frequent, yet severe side effect, rhabdomyolysis, or the breakdown of muscles.
The client should seek physician clearance before continuing with any massage or bodywork to avoid long-term complications and damage to the kidneys.
Other common side effects that might impact massage include indigestion and constipation. If the client has been constipated for several days and is taking bile-sequestering drugs such as Colestid, Questran or Prevalite, massage is contraindicated, and the client should be referred to a physician.
As many as 30 million adults in the U.S. have diabetes, according to the CDC, and type 2 diabetes accounts for 90 to 95% of all diabetes diagnoses.
When diet and exercise are no longer a viable treatment, glucose management medications are prescribed. Glucophage (metformin), which is the most widely prescribed diabetes medication in the world, increases glucose sensitivity and suppresses glucose production. Glucotrol (glipizide) or Diabeta (glyburide) work by stimulating insulin production by the pancreas.
If a client is unsure how massage affects him, or if he has recently started a new medication, it may be a good idea to have him check his blood glucose before and after the session. It is recommended that clients eat a light snack before the session, and always have something easily accessible in case of a hypoglycemic episode.
Be aware that some of the side effects of diabetes medications may include symptoms such as back pain, numbness and tingling in the extremities. It is important to be aware that these medications may cause them to bruise easily, so work slowly and modify pressure when appropriate.
If the senior massage client seems lethargic, disordered or confused during or after the session, this is a medical emergency, and you may need to call 911. For insulin-dependent clients who are prescribed medication via parenteral routes, use caution around injection sites.
Many clients receive massage for pain relief, soreness, stiffness and injury recovery. Massage is not the only remedy for what pains us, which tells us that many of our clients will be assisting that pain relief with over-the-counter and prescription medications.
Over-the-counter categories include salicylates, such as aspirin; acetaminophen, such as Tylenol; and nonsteroidal anti-inflammatory drugs (NSAIDS), such as Advil or Aleve. Commonly prescribed NSAIDs include Celebrex and Voltaren.
Clients taking aspirin may bruise easily and fast, so deep tissue techniques are not indicated. NSAIDS, when taken in high doses, may cause fatigue, drowsiness, back pain and edema in some clients.
For more severe and chronic pain, clients may be prescribed narcotic, or opiate pain medications. Frequently prescribed opiate medications include Codeine, Hydrocodone, morphine and Oxycodone.
The side effects of these medications can have significant interactions with massage, including hypotension, dizziness, sedation and drowsiness.
Because of the sedative quality of these drugs, massage therapists are urged to use stimulating techniques such as fast-paced effleurage and tapotement. Deep tissue techniques are not recommended due to the limited pain perception caused by the medication.
The therapist may need to assist the client in getting up from the table, and the client should pay close attention to any feelings of dizziness or imbalance.
According to the CDC’s Antidepressant Use in Persons Aged 12 and Over: United States, 20011–2014, released in 2017 and the reflecting the latest statistics available, 16/5%% of women over age 50 take antidepressant medication, while 8.6% of males in that age range do so.
The most commonly prescribed is Zoloft (sertraline hydrochloride), a selective serotonin reuptake inhibitor, or SSRI. Others include Celexa, Lexapro, Prozac and Paxil. Like most of the medications that have been described in this article, massage does not affect the absorption rate.
The concern is that massage may intensify some of the side effects, including hypotension and lethargy. In most cases, the benefits of massage can help reduce insomnia or anxiety associated with the medication.
When in Doubt, Refer Out
When working with aging adults, the likelihood that massage therapists will encounter the side effects of medications in our practice is high. We need to be aware of how massage can affect the clients’ experience and adapt sessions as needed.
Above all else, it is imperative we recognize when to refer them to their physician. Medications of concern for massage therapists are not limited to those mentioned in this article. Every massage practice, clinic or spa should keep a reference guide for medications handy alongside a current pathology book.
Continuing your education regarding common medications and massage is necessary to ensure that massage is both safe and effective for our clients.
About the Author:
Hope DeVall, LMBT, is CEO and educator at the Western North Carolina School of Massage in Asheville, North Carolina. DeVall teaches both massage students and licensed therapists a wide variety of courses, including ethics, pathology and massage for special populations.