Massage + Medication

There are common conditions that can sometimes require massage therapists to alter their treatment plans—either because of the symptoms of the condition or because of side effects of the medications. Brent A. Bauer, MD, FACP, Director, Complementary and Integrative Medicine Program at Mayo Clinic, says there are precautions all massage therapists should take when starting a treatment program—especially if the client is taking medications. According to Bauer, “one common medication that may require treatment alterations is anticoagulant medications [blood thinners] like Warfarin because they may make your clients more prone to bruising and internal bleeding.”

John S. Stracks, MD, family medicine physician at Northwestern Medicine Osher Center for Integrative Medicine in Chicago, says, “The massage therapists who work with my practice say they are always careful when giving deep tissue massage to someone on narcotic pain relievers.” This is because their pain perception may be altered and there is risk for overtreatment. But there are many medications that can cause side effects that massage therapists need to be aware of.

Following, you’ll find information on some common diseases that require medication, as well as some of the side effects and how a massage therapy session may need to change to accommodate clients taking medication.

Common Conditions that Require Medications

Arthritis. Arthritis is a condition that affects the joints. There are many types of arthritis, but the most common types are osteoarthritis and rheumatoid arthritis. The main symptoms of arthritis are joint pain, stiffness and swelling, redness, and a decreased range of motion. Arthritis is typically associated with age, but younger people can suffer from arthritis, too. Age, joint injury and obesity are all risk factors for developing arthritis.

The most common treatment for arthritis is medication. Pain relievers, such as analgesics (acetaminophen, tramadol, and narcotics) and non-steroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen and naproxen) are often prescribed for arthritis. Some people with arthritis also take corticosteroids (like prednisone and cortisone) or disease-modifying antirheumatic drugs (DMARDS) and biologics (including etanercept and infliximab).

You should consider altering treatment plans for anyone taking pain relievers. When people take pain relieving medications, they may experience altered pain perception, low blood pressure, dizziness, and bleeding or bruising.

Corticosteroids, too, can cause swelling of the legs, thinning of the skin, tendency to bruise, high blood pressure and a weakened immune response. Long-term use of corticosteroids can cause osteoporosis, which increases risk of bone fractures. If your client is taking corticosteroids, avoid the injection site during massage (if medications are injected), and avoid deep tissue work, opting for more gentle strokes instead.

Diabetes. Diabetes is a condition caused by too little insulin in the blood or an inability of the body to use insulin. Type 1 diabetes often begins in childhood. Type 2 diabetes most often begins during adulthood, but children can develop Type 2, as well.

Uncontrolled diabetes can cause excessive thirst and urination, fatigue, wounds that are slow to heal, frequent infections, blurred vision, and tingling in the hands and feet. Most people with diabetes will take some kind of medication. Common types are insulin, metformin (Glucophage and Glumetza are two brand names) and thiazolidinediones (Actos and Avandia are two brand names).

Before beginning massage therapy on a person who is being treated for diabetes, get a physician's referral for massage. You may also want to start with shorter massage sessions to see how therapy affects your client's diabetes or the side effects of medication. When scheduling massages, make sure to do so during peak availability of the medications, and make sure your client has eaten prior to the session.

Some of the side effects of diabetes medications are numbness and tingling, especially in the extremities, easy bruising, swelling, muscle pain, back pain and abdominal pain. When you are performing massage on a person with diabetes, look for any wounds, and ask whether your client is experiencing any sensory loss or alterations, tingling or numbness, leg cramps, fatigue and muscle weakness.

People with diabetes are at risk of hypoglycemia (also known as insulin shock), which can be life threatening. If your client is insulin dependent, meaning they are being treated with insulin, make sure they’ve checked their blood sugar levels prior to the massage therapy session. Clients who are insulin dependent should always have a source of sugar (glucose) available. In case your client forgets, you should keep fruit juice or regular (not diet) soda on hand in case your client’s blood sugar drops. Call 911 if your client is drowsy or confused, or is difficult to rouse after massage.

Clients who take Diabenese or Glucotrol in combination with other drugs, such as non-steroidal antiinflammatory drugs (NSAIDs), aspirin, ACE-inhibitors, SSRIs, and even ginseng supplements, are at higher risk of hypoglycemia, so be especially aware of your client’s symptoms and behaviors if he or she is taking a combination of drugs.

Fibromyalgia. Fibromyalgia is a musculoskeletal condition that causes many symptoms, including widespread pain all over the body, points on the body that are painful and tender to touch, joint and muscle stiffness in the morning, and fatigue. Clients with fibromyalgia might also experience numbness and tingling in the extremities, as well as other uncomfortable and even debilitating symptoms.

Fibromyalgia can affect anyone, but it affects women far more than men, and it is more common in women who have gone through menopause. The most common first-line treatment for fibromyalgia is antidepressant medication because it can help relieve pain, reduce fatigue and improve sleep problems. Pain relieving medications (generally analgesics) may also be prescribed, as well as muscle relaxants (such as Soma, Parafon, Forte, Flexeril, Skelaxin, and Myolin) or anticonvulsants (often Lyrica is prescribed for fibromyalgia).

Antidepressants can cause dizziness, drowsiness, and fatigue, along with a tendency to bruise, depressed stretch receptor response and altered temperature perception. Watch for bruising, and avoid deep tissue work if bruising is present or occurs during massage. Also, be aware of the potential for over stretching muscles. Watch for signs of dizziness, drowsiness, altered consciousness and fatigue, and adapt your massage therapy session as necessary.

Parkinson’s disease. Parkinson’s disease is a nervous system disorder that affects movement, often developing gradually and beginning with a small hand tremor and progressing over time. The most common symptoms are tremors, rigid muscles, slowed movement, impaired posture, balance problems, loss of automatic movements (such as blinking and arm swinging), and speech changes. There is no cure for Parkinson’s yet, but medications can improve symptoms.

There are a number of drugs used to treat Parkinson’s disease, including parasympatholytics and dopaminergicsLevodopa (Dopar, Larodopa, and Lidopa) is the most common drug prescribed for Parkinson’s.

Some symptoms to look for if your client is taking drugs for Parkinson’s are dizziness, drowsiness, disorientation, nervousness, and low blood pressure when changing position (orthostatic hypotension). To help muscles relax, try using effleurage and rocking strokes, and possibly some petrissage. If your client is too relaxed or sedated, use some stimulating strokes toward the end of the massage, such as tapotement and fast effleurage. If your client is dizzy, drowsy or disoriented, offer to help him or her get up from the table.

Cardiovascular disease. Cardiovascular disease is a term that encompasses a number of diseases and conditions of the heart and blood vessels. Coronary artery disease, heart failure, vascular disease (disease of the blood vessels), heart valve disease, and other diseases of the heart all fall under the category of cardiovascular disease. In the United States, it is the leading cause of death in both men and women. People who have cardiovascular disease are at greater risk for heart attacks and strokes. Symptoms vary depending on the type of disease, but angina (chest pain), chest discomfort, shortness of breath, heart palpitations, dizziness, fatigue, weakness, and swelling are common symptoms of most forms of cardiovascular disease.

Medications are a common way to treat cardiovascular disease, and there are many types of medications used by doctors today. These include beta blockers, antihypertensives, anticoagulants/blood thinners, calcium channel blockers (CCBs), sodium channel blockers and ACE-inhibitors, among others. The drugs can cause low blood pressure, easy bruising and bleeding, swelling in the legs (that can lead to deep vein thrombosis), cough and heart rhythm problems, among other symptoms.

Low blood pressure, dizziness, and drowsiness are common side effects of a number of drugs used to treat cardiovascular disease. If your client is taking any of these drugs, consider limiting long sessions of effleurage because it can add to the effects of the drugs. Monitor your client throughout the session, and assist them with position changes. You may want to end sessions with stimulating strokes, such as tapotement, to help bring your client back to an alert state. This is especially important if you notice signs of drowsiness or your client complains of dizziness.

When the session is over, help your client to a seated position and stay with him or her until dizziness or drowsiness subsides. Please note that you should not use stimulating strokes like tapotement if your client has a severe arrhythmia because it can destabilize the heart rhythm.

Additionally, make sure clients with cardiovascular disease regularly check with their primary care physicians to verify massage therapy is suitable.

Common Side Effects of Medication

In order for you to ensure your clients’ safety, you also need to understand how some of the common side effects of various medications can affect your clients and, in turn, how you proceed with a massage therapy session.

Low blood pressure and/or orthostatic hypotension. There are a variety of medications that can cause these side effects, including, but not limited to:

  • Muscle relaxants
  • Dopaminergics
  • Narcotic pain relievers
  • Antihypertensives (sympatholytics, ACE-inhibitors, and vasodilators)
  • Diuretics
  • Antiarhythmics
  • Beta blockers
  • Calcium channel blockers (CCBs)

If your client is taking one of these medications, suggest that they move slowly from position to position, and consider helping them up from the table when the massage therapy session is over. During massage, especially toward the end of the session, use strokes that are faster and more stimulating. However, avoid deep tissue work if your client is experiencing numbness or tingling.

Remind your clients to sit up and stand slowly, and to take their time getting dressed. If your client complains of lightheadedness or dizziness, have them lie down until these symptoms pass.

Dizziness. Dizziness and lightheadedness are common side effects of a number of medications, including, but not limited to:

  • Medications used to help treat Parkinson’s, including dopaminergics
  • Narcotic pain relievers
  • Diuretics
  • Cardiovascular drugs (beta blockers, calcium channel blockers, antiarythmics and vasodilators)
  • Antidepressants

To help alleviate dizziness, use faster strokes toward the end of the massage, increasing speed as you go, and finish the massage with tapotement. Make sure your client isn’t experiencing dizziness before they get up from the table, and offer assistance if necessary.

If your client feels dizzy or complains of lightheadedness during or after a massage, have him or her lie flat until the feeling passes.

Bruising. Bruising can occur for a variety of reasons, including thin blood, blood vessel problems, anemia, and thin or weakened skin. There are some medications that make bruising more likely, so you should be aware of the potential of bruising and alter strokes and modalities accordingly.

Some common medications that can cause easy bruising are:

  • Anticoagulants (blood thinners)
  • Non-steroidal anti-inflammatory drugs (NSAIDs)
  • Aspirin
  • Corticosteroids

If your client is taking any of these medications or you notice any bruising, avoid deep tissue massage and strokes such as deep kneading, muscle stripping and trigger point compressions. Instead, use gentle compression, friction and pertrissage.

Muscle cramping or weakness. Antidiabetics, calcium channel blockers (CCBs), beta blockers and diuretics can all cause muscle cramping or weakness. If your client is experiencing these symptoms, you may want to postpone or reschedule massage therapy, or ask for a physician’s clearance before beginning or continuing therapy.

Weakened body tissue. Corticosteroids can cause weakened body tissue. If you notice any clinical signs of tissue weakness or damage, avoid massaging those areas. If your client is taking corticosteroids, do not use deep tissue massage.

Also avoid friction, deep kneading, joint mobilization, muscle stripping and passive forced stretching techniques, or modify them to reduce risk to your client.

Blood clotting. Some medications, including corticosteroids and calcium channel blockers (CCBs), can cause deep vein thrombosis (DVT) and thromboembolism. Avoid using deep, kneading strokes, especially on the legs, and monitor your client for signs of DVT (pain, redness and warmth) or embolism (including sudden pain in the chest or head).

Drugs given by injection or patch. If your client receives any drugs by injection, such as corticosteroids, hormone replacement or insulin, avoid the injection area. Do not perform any deep tissue work near the injection site.

If your client wears a medication patch, avoid massaging the area around the patch, and do not remove or move the patch at any time.

Similar precautions should be taken with any hormone cream or topical medication.

Of course, not all people who take a medication will experience side effects. But it’s important for you to be aware of what the potential side effects are so you can monitor your clients for signs of problems. If you’re ever concerned that massage therapy might not be safe for your client, request a physician release for massage.

Getting the Information You Need

Doing a thorough intake is a necessary part of any massage therapy session, but especially so when you have clients who may be taking medication for acute or chronic health conditions. Having important health information, like what medications your clients are taking—as well as knowing the possible side effects of medication—helps you ensure client safety.

Verbal Intake: Questions you Should Ask New Clients

  • Are you taking any medications, including over-the-counter drugs, vitamins and supplements?
  • If so, why do you take the medications?
  • If you take medication, how often do you take it, and what time of day do you take it? (This is especially important for medications like antidiabetics, pain relievers and cardiovascular drugs.)
  • Do you experience any symptoms or side effects, such as dizziness, fatigue, pain, tingling or numbness, low or high blood pressure, skin problems or bruising?
  • Are you taking the medication long-term or for a limited time?

Having all of this information will help you better assess what, if any, adjustments need to be made to the massage therapy session. For example, a client who is taking medication long-term versus for a limited time may have different needs and considerations, especially for, say, corticosteroids, where long-term use may cause muscle weakness and edema.

Visual Assessment: Things You Should Look and Feel For

Along with clients filling out an intake form or performing a verbal intake, massage therapists can learn a great deal about a client through visual assessments, as well. Some medications, for example, may cause swelling or differences in gait or movement patterns that need to be investigated prior to a massage therapy session to ensure the cause isn’t one that would contraindicate massage.

Some of the signs and symptoms you should look out for include:

  • Unsteady gait or changes in gait
  • Apparent dizziness or drowsiness
  • Confusion
  • Change in skin color (Is your client pale or flushed?)
  • Swelling of the face, legs or ankles
  • Facial expression
  • Physical deformity or irregular posture
  • Changes in speech

Additionally, you may be able to detect some symptoms and side effects by palpating your client’s skin:

  • Increased perspiration and cool or clammy skin can occur when people take non-steroidal anti inflammatory drugs, which might require you adjust a massage therapy session.
  • Loose muscles that are easy to maneuver can be a side effect of muscle relaxants and central nervous system depressants, which can lead to overstretching.
  • Fragile skin and soft hypotonic muscles can be a sign of tissue breakdown, which can happen when people take corticosteroids for a long period of time.
  • Nodules or fibrous tissue can grow near injection sites, especially when the same site is used over and over again. Avoid these sites, especially after recent injections.
  • Swelling (edema) can often be felt as well as seen.

Many medications can cause swelling, as can a number of conditions. Watch for swelling, and if you encounter it, talk with your client. Swelling, warmth and redness in the legs may indicate deep vein thrombosis, which may contraindicate massage. If you notice warm, red spots on the legs, avoid deep tissue massage, and consider asking your client to get a physician’s referral.

Ways You May Need to Alter the Massage Session

Most medications will not require you alter a client’s massage therapy session, but some will. If your client is taking medication, you may need to alter massage scheduling, the area of focus during the massage, the duration of the massage, as well as the modalities you will use during the session.

Scheduling. You may want to schedule massage therapy sessions to coincide with medication dosing schedules. For example, if your client takes a pain medication, it is best, if possible, to schedule massages when your client isn’t taking the medication or just before they’re due for their next dose. Because pain medications can alter sensations, they may interfere with your client’s ability to provide accurate feedback about depth of pressure.

Some conditions, like diabetes and epilepsy, require that medication levels remain consistent and bioavailable throughout the day. Because there are some massage strokes that can potentially affect the bioavailability of drugs, massages should be scheduled during periods of peak drug levels. If you’re uncertain about when peak levels are achieved for a certain medication, ask your client to get a physician’s referral that includes best times to schedule massage.

Adapting length of massage. Some medications can cause mood-related symptoms, such as anxiety, irritability and depression. Consider reducing session length if your clients report feeling changes in mood. If your client is taking pain relieving medication and you aren’t able to schedule massage between dosing (or right before or after a dose), you may want to offer shorter sessions to reduce the risk of overtreatment.

Also, when you have a new client who is taking cardiovascular medication, pain relievers or antidiabetics, recommend starting with shorter sessions and building up to longer sessions slowly so you can both gauge how massage therapy helps and when it’s most effective. You might also consider delaying the use of deeper strokes until you can be assured your client is able to provide accurate feedback, particularly with clients who take medication that may alter sensation.

Area of focus. There are times when you will have to change your area of focus for clients who are taking medications. For example, you should always avoid injection sites for clients who have been given medication via injection (insulin, corticosteroids, hormones, etc.) You should also avoid massaging the legs if your client is on medication for blood clots in the legs. Some medications can cause constipation, and massaging the abdomen can help relieve that.

Modalities to use, avoid or adapt. Medications may also require you to adapt the modalities you use during a massage session. For example, if your client is taking pain relieving medications that can increase sedation, you should end each session with faster, invigorating strokes, such as fast friction, fast effleurage and tapotement. The same is true for clients who are taking medications to lower blood pressure or cause orthostatic hypotension, like narcotics and antihypertensives.

If your client is taking medication that increases risk for blood clots or deep vein thrombosis, avoid deep tissue massage, and if low blood pressure or orthostatic hypotension is a concern, use fast, invigorating strokes toward the end of the session.

Remember, too, to use great care when employing deep tissue massage and strokes like pertrissage, friction and compression when high blood pressure, blood clotting, bruising, or muscle or tissue weakness are a potential problem. Here, massage therapists may want to rely more on Swedish massage and gentle strokes, such as rhythmic effleurage and rocking.

Stay in touch with your clients. Checking in with clients who are on medication—both during a massage therapy session and regularly before beginning sessions to ensure nothing has changed—is going to be particularly important. Ask them throughout the session if the pressure is ok, for example, and provide assistance should they need help once the session has ended. If there is new swelling or a change in a client’s condition, ask that they get a physician referral before a massage therapy session to ensure their safety.

As the population continues to age, massage therapists will likely see more clients who are coming to them with either chronic or acute disease—many of whom may be on at least one medication. Understanding and keeping up to date on how medication use impacts massage therapy is critical for keeping your clients safe.

Continue Learning & Earn CE Credit

Learn how to minimize the risk of massage aggravating side effects from medications, including information on major drug side effects and groups of medications that require special attention.

Start learning: Massage & Medication—When Is Therapy Dangerous | 3.5 Credit Hours

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