Positive Health Online

Doreen, like many elderly people, has a complex medical picture. She has lower back pain due to wear and tear on her dorsal intervertebral discs, which causes occasional sciatic pain, chronic asthma and a tendency to develop bronchitis in winter, hypertension, varicose veins, angina (one of three arteries to her heart are partially blocked), and there is oedema in both legs. She has right shoulder pain and restricted mobility, which has deteriorated over the last two years. Her thumb joints are arthritic, and she has an inoperable torn cruciate ligament.

Pause for thought – how to massage her safely without aggravating any of these conditions? And how could massage help alleviate pain or tension? Cardiovascular conditions indicate a letter to the doctor asking if she has any concerns about the advisability of massage. The cause of the oedema is unclear, so best to avoid draining strokes on the legs – but these would be contraindicated anyway by her varicose veins. High blood pressure indicates not too long lying on her front, no deep strokes, no percussion. With her knee problem, she may need assistance getting on and off the table.

Her thumbs could do with some gentle rotations to assist production of synovial fluid, and her shoulders and lower back could do with regular massage, since the muscles there are probably contracting around the pain. Her intercostals and breathing muscles are likely to be tight.

But this is not all. Doreen also takes various forms of medication: bendrofluazide, enalapril, steroids, co-proxamol and doxazosin, a list as daunting as her medical conditions. However, a little internet searching informs me that the first is a diuretic, the second for hypertension (high blood pressure), the steroids relieve her shoulder pain, the next one is an analgesic (pain killer) prescribed for arthritic conditions and doxazosin is an alpha-adrenergic blocker, which means that it causes the blood vessels to relax. This is even more information to take into account when planning a treatment. Doreen may need to use the toilet before her massage, or even during, if she's taking a diuretic. The analgesic and the steroids both mask pain, so she may not be able to give accurate feedback if the pressure is too deep. The steroids will reduce inflammation in the shoulder area, but if the cause of the pain is underlying tissue damage, it's probably unwise to try stretches or rotations. The doxazosin may make bruising a possibility, yet another reason to avoid deep massage.

Drugs are prescribed to alter the physiology of the body when something has gone wrong. Since massage can also alter the physiology of the body, there is the possibility that a person on prescribed drugs may respond in an unpredictable way. For example, a client who is using ibuprofen, a common analgesic for muscular pain, on a sore calf muscle may experience pain and bruising after some deep work on the muscle, because ibuprofen reduces the clotting ability of the blood. Another factor to consider is that the side effects of some medication mimic common ailments. Some anti-depressants cause aching in the muscles and joints. If your client on anti-depressants isn't getting any physical benefit from massage, this may be the reason. So it's important to take not just a full medical history, but also to ask a new client for names of prescribed drugs. And if she doesn't remember, ask her to check the labels on the medication and write it down for you. It's also important to know how a drug is administered. If medication is taken orally, or as drops into the eyes or ears, a massage won't interfere, but if it's a cream or ointment applied onto the skin, that area should be considered a local contraindication as should sites of injected drugs.

The best site for reliable information about medication belongs to the British National Formulary (www.bnf.org). This information is complied by the British Medical Association and the Royal Pharmaceutical Society. All prescribed drugs are listed, the conditions for which they are recommended, how they work and possible side effects. Much of the information, being aimed at medical professionals, is too detailed to be of use, but at least you can find out what a named drug has been prescribed for, and whether there are any things to watch out for, as a massage practitioner. For example, Alice had rheumatoid arthritis and told me she was taking sulfasalazine and methotrexate. Checking with the BNF informed me that both these affect the immune response and suppress the disease process. From the long list of possible side effects, I note that rashes, bruising and anaemia, and peripheral neuropathy are possible so I know to look out for these and watch the pressure I use.

Here's another example where knowing about drug side effects was useful. Kathleen has enjoyed a massage every two weeks or so for the last twenty years, and claims that's what's kept her going so well. Her health has been pretty good most of her life. In the last few years she's had a couple of small TIA's (transient ischaemic attacks) and as a result, she now takes warfarin, an anti-clotting medication, which 'thins the blood'. Kathleen now bruises very easily; even carrying heavy shopping can result in bruised fingers. So I only use very gentle massage techniques on Kathleen.

But after she began to take lipitor, one of the drugs known as statins, in October 2007 to reduce her cholesterol levels she complained more about her back pain, about little aches and pains all over, she was always tired and she became increasingly forgetful. Early in 2008 she celebrated her eightieth birthday and for a while I thought I was witnessing one of the sudden declines that the elderly can go through before stabilizing again. But when I looked up statins and found that her symptoms were identical to the side effects, I suggested she talk to her doctor about this possibility, but she said she'd never remember the detail and could I write a letter for her. I did, the doctor was happy for her to stop taking the lipitor, and a few months later her energy levels and her mental alertness have both improved considerably.

A little basic knowledge about prescribed drugs does not make us medical professionals or entitle us to inform clients about their use, but it should be an essential part of our knowledge base to ensure that we massage safely, just as knowledge of common pathology helps us make sound decisions about when, what and how to massage.

References:

Su Fox Practical Pathology for the Massage Therapist. Corpus Publishing Limited. 2005.
Randall S. Persad. Massage Therapy and Medications. General Treatment Principles. Curties-Overset Publications Inc. Toronto. 2001.