About 25 million Americans currently use a statin drug to manage their risk of cardiovascular disease related to unhealthy levels of cholesterol. If the recommendations of the American Heart Association and the American College of Cardiology regarding statins are followed, that number will soon increase to about 56 million adults.
Statin Use—and a Question
Statins are drugs that alter the cholesterol levels in our blood, with the goal of reducing the risk of a major cardiovascular event—that is, a heart attack or a stroke. In this column, we will look at how statins are used, and we will hone in specifically on a common side effect of statins: muscle, tendon, and joint pain. This phenomenon is so common that it has a name: statin-associated musculoskeletal symptoms, or SAMS.
This topic came to me, as many do, by way of an interesting thread on Facebook, in which a massage therapist was wondering whether massage therapy was appropriate for a client with SAMS. Someone said, “Ask Ruth,” which they did. I was stumped. I had no idea whether it was safe and appropriate for a person with SAMS to receive massage therapy—which brings us to this point.
Before we proceed, I would like to take a moment to thank the people who brought my attention to this complicated question and those who shared with me their stories of working with clients who live with this condition.
Who Uses Statins?
The incidence of heart disease is high in this country. Heart attacks are our leading cause of death, and stroke is not far behind; combined, these cardiovascular events kill some 775,000 people each year.
Diet and exercise habits (or lack of them) are major contributors to the risk of cardiovascular disease, and correcting these factors can improve a person’s outlook a great deal. But for some people, diet and exercise are not sufficient, and they may benefit from pharmacological interventions to decrease their heart disease risk.
Statins are a class of medications that are used for people with very high LDL (low density lipoproteins) and VLDL (very low density lipoproteins). These are cholesterol carriers, and elevated levels are associated with an increased risk of heart attack and stroke. Statins are recommended when diet and exercise do not lower LDL or VLDL levels, and when at least one other risk factor for a serious cardiovascular event is present. This description encompasses a significant portion of American adults, although not all of them currently use statins.
If you’re interested, risk factor predictors for cardiovascular disease are widely available. Many doctors use the
heart risk calculator at www.cvriskcalculator.com, published by the American Heart Association and American College of Cardiology, to inform their decisions about recommending statins for patients whose risk is identified to be over a certain number. (That said, not everyone agrees about the accuracy of these risk predictors, so I recommend taking this with a grain of salt.)
Statins can be prescribed as “primary preventives,” that is, when risks are present but the individual has no history of heart attack, stroke, or other cardiovascular emergency, or as “secondary preventives” when the individual has a history of some significant problem and wants to decrease the chances of a repeat episode.
How Effective are Statins?
Data on the safety and effectiveness of statins have been collected for decades. While most studies point to benefits and a reduced risk of heart attack and stroke for whole population groups, when we drill down to individuals, those benefits become harder to pin down. This is the pattern with many preventive measures: it is difficult to demonstrate a statistical or clinical benefit for a single person, but when we look at large groups over time, we can see a downward trend in the incidence of a problem—in this case, of heart attack and stroke.
Another kink in the statin effectiveness discussion is that while the use of these drugs correlates with positive changes in cholesterol readings and cardiovascular risk, we do not have universal consensus that the link between those changes is causative. In other words, did a person’s heart attack risk decrease because of changes in cholesterol, or because of some other action that statins have? Some statins are also decent systemic anti-inflammatories, and it may be this action that has the greater impact on whether a person develops dangerous atherosclerosis.
Furthermore, statins are not a risk-free intervention. Their side effects sometimes make them impossible to use. Among the side effects noted with these drugs are a slightly increased risk for developing type 2 diabetes, some cognitive symptoms (fuzziness, loss of short-term memory and concentration), digestive discomfort, and the topic of this article, SAMS.
Statin-Associated Musculoskeletal Symptoms
It is well recognized that a substantial proportion of people who use statins develop some muscle and joint pain—SAMS. Some resources use the acronym SIM, for statin-induced myopathy.
SAMS can include muscle pain, cramping, weakness, tendinopathies (usually at the Achilles tendon), and diffuse-aching pain. Back pain is common, and many people report achiness and stiffness at proximal joints: shoulders and hips. The pain is typically bilateral, although one side may be worse than the other.
For most affected people, SAMS appears to cause diffuse and widespread pain. But the medical record has some reports about patients with much more specific damage, including ruptured tendons and rhabdomyolysis (muscle breakdown that can damage the kidneys).
SAMS is found most often in patients who have some combination of these risk factors: they are female, they have a low body mass index, they are 65 years old or older, they use an additional drug to manage cholesterol, they have a history of kidney or liver disease, or they are vitamin D deficient. People outside this profile can also develop SAMS, but this is the most commonly observed pattern.
SAMS usually has a specific onset: it develops within a couple of weeks of beginning a new prescription of statin drugs. One of the ways to confirm that a person’s pain is related to their prescription is for them to stop using the medication for two weeks. If symptoms go away, then SAMS is confirmed. In this case, it is a good idea to make some adjustments, change the dose of the medication, or switch to a different statin.
If the symptoms don’t subside with a two-week break from the medication, then the problem is likely not to be related to statins. In this case, a different solution for musculoskeletal pain, including massage therapy, can safely be sought.
Many people report that their SAMS symptoms are severe enough to negatively impact their quality of life, but an open question remains: How many people experience low-level muscle aches and pains that they never associate with their statin use? And how many of them may seek massage therapy for these symptoms?
How common is SAMS? It depends on who you ask. Estimates range from about 2 percent of statin users (with the strictest quantitative criteria) to 29 percent (from observational data). Most experts agree that more than 10 percent of statin users will develop SAMS. In the United States, that means that 2.5 million people or more may live with this problem.
How is SAMS Treated?
When SAMS is identified (and the trial cessation of the drug should only happen under a doctor’s supervision), then a number of options can be tried.
Doctors will begin by looking for modifiable risk factors for SAMS. Many patients find their symptoms subside when they supplement vitamin D or CoQ10 (an enzyme that protects tissues from free-radical injuries). If these adjustments work, a person can use their statin without accompanying musculoskeletal pain.
Sometimes these supplements are not sufficient, however. At this point, the doctor and patient must assess the risk/benefit ratio of the medication. This may lead to changes in the prescription, such as lowering the dose or changing to another type of statin. In rare cases, even this is not sufficient, and the doctor and patient must consider nonstatin alternatives to managing cholesterol levels.
Proceed with Caution
This topic has been challenging to write about, because while an abundance of information about statins and their side effects is available, we don’t have any well-supported information about whether massage therapy is a good idea for someone who has statin-associated musculoskeletal symptoms.
If you are totally confused at this point, I don’t blame you. I hope the flow chart we’ve created on page 38 might help you follow all the routes to “massage therapy is OK”—with the understanding that massage therapy is always adapted to whatever other cautions may be present, of course.
I don’t mean to suggest that we can’t touch clients with SAMS. The types of massage therapy or bodywork that I suggest to avoid for these clients include any technique that focuses on pushing a lot of fluid through the body (e.g., petrissage-heavy work) and any work that may challenge the structural integrity of muscles, tendons, or ligaments that might be compromised by medication (i.e., intrusive or painful frictions or stretching). Bodywork that is less challenging to receive is probably safe, but I still recommend conservatism and follow-up with clients to check on their well-being.
It is important to emphasize that these suggestions are just that: suggestions, based on lots of information, but no systematically collected data as of yet.
This isn’t for lack of trying! I looked for research on SAMS and massage; I found nothing. Then I searched for recommendations about exercise—which can sometimes serve as an indication about the safety of massage therapy—and found that exercise and stretching are not among the conventional treatment options for this problem.
I discussed this question with a couple of medical professionals in my circle, and the conclusion we came to was this: if someone needs statins, and has identified SAMS, then rigorous massage therapy is probably not an ideal intervention. Instead, what their massage therapist can do is strongly advise them to pursue this problem with their prescribing physician. Statin medications can be adjusted for dosage or type—and if this is not satisfactory, then other strategies for lowering cardiovascular risks can be tried.
To make a confident prediction about the safety of massage therapy for a client with SAMS, we need to know why people sometimes develop musculoskeletal pain as a side effect of statin use, and that is still an open question. One theory suggests that the enzymes limited by some statins also impact growth and repair in muscles and tendons, but this has not been firmly established yet. Research suggests that statin use may negatively affect the structural integrity of some connective tissues. Some patients with SAMS experience a rise in creatine kinase levels, which suggests muscle inflammation. And statins have a low-but-not-zero association with muscular breakdown that can cause kidney damage and potentially dangerous rhabdomyolysis.
For all these reasons, my advice is to proceed with caution. The best choice is to encourage the client to consult with their prescribing physician so they can make adjustments, or change their dosage or prescription to a different statin that doesn’t cause SAMS. Then, we can design a massage therapy strategy that is customized to fit that client’s ability to adapt to the homeostatic challenges our work may bring about.
But if a person has some milder or subtler signs of SAMS, and if they choose not to pursue a change in medication, then any massage therapy must be conservative and incremental—not looking for big changes (that require substantial homeostatic adaptation), but for smaller, cumulative improvements in symptoms.
Do you have clients who have SAMS? Do they seek massage therapy to help with their symptoms? Perhaps now you have some clearer ideas about the risks and benefits of working with this population. Please do us all a favor, and with the permission of the client and the cooperation of their prescribing physician, write a case report about massage therapy for someone with SAMS, and share your wisdom with the world.
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.
Resources
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