When I entered the massage therapy field, it was well accepted that practitioners needed to know at least a little bit about contraindications: situations in which massage therapy might cause damage. I felt drastically underprepared to make good decisions about contraindications at the beginning of my career, and that led me to learn more (and then to teach and write) about pathology in the context of massage therapy—and this became an enduring passion for me.

But adjacent to pathology is the whole field of pharmacologic interventions used to treat or manage diseases and conditions, and, at least in my generation, we received no education about that topic at all. In fact, I learned that if a client needed medication to manage their high blood pressure, then they were probably not a good candidate for massage anyway. (How many clients would you have if you followed this advice?)

Happily, that lack of any education about pharmacology in massage school is no longer universally true—many massage therapy programs now include information about medications. Nonetheless, I continue to find that many massage therapists seem eager to learn more about the drugs their clients use and how massage might influence those situations for better or worse. And because I teach and write about pathology, I am often the person people ask for this information.

This is highly ironic, given my lifelong avoidance of learning anything—anything—about chemistry. But in a way, that makes me a useful communicator about this topic, because I find I am not alone in this attitude. With that in mind, what follows is a chemistry-light beginner’s introduction to the world of pharmacology, with an emphasis on massage therapy accommodations and adjustments.

What is a Drug?

A well-accepted definition of drug is: a natural or synthetic chemical substance that alters physiology when taken into a living system. Under this definition, substances like caffeine, alcohol, and even sugar could be considered drugs.

Not all drugs are medications, however. A drug is a medication when it is intended to improve health in some way. Medications can be used to help diagnose, treat, or prevent conditions, or manage them for long-term maintenance.

Medications vary from dietary supplements in a couple of important ways. Supplements are defined as substances taken to complement the diet for full nutrition. They are not strictly regulated, and as such, they are assumed to be safe unless demonstrated otherwise. By contrast, medications are carefully regulated and are assumed to be potentially dangerous until safe limitations for use are established.

Drug Nomenclature and Classification

The label on the container of an over-the-counter or prescription medication may have multiple names for the drug inside. These names typically include the following: a chemical name (e.g., acetylsalicylic acid), a generic nonproprietary name (e.g., aspirin), and a trade name (e.g., Bayer or Bufferin).

Drugs are often classified by groups, but these groups can be arranged in many different ways. For example:

Chemical Classes. Medications may be described by the chemical compounds they contain. Benzodiazepines are an example: This group of drugs is built on a particular chemical structure, and under this classification we find diazepam (Valium), clonazepam (Klonopin), and alprazolam (Xanax).

Intended Mechanisms. Another way to talk about medications is by what they are intended to do. When we talk about vasodilators or analgesics, this describes medications by their function. Drugs grouped in this way may have different chemical structures, though. Both acetaminophen (Tylenol) and ibuprofen (Advil) are fever reducers, but their chemical structures are different.

Conditions Treated. Medications may also be classified by what conditions they are used to treat. These classes include anxiolytics (antianxiety medications), antihypertensives (drugs to treat high blood pressure), anticonvulsants (drugs to suppress seizures), and many others.

A few other classification systems might be used by prescribing physicians and pharmacists, but they aren’t relevant for this discussion.

Drug classifications aren’t rigid, and many drugs are used for more than one purpose. Aspirin is an analgesic, but it is also used as an antiplatelet drug. Amitriptyline (Elavil) was developed as an antidepressant, but it can be useful to control migraines or as a sleep aid. Gabapentin was designed to be an anticonvulsant drug, but it works well to manage neurogenic pain, so it is also an analgesic. It is always good news when we find that a medication that has a history of safe use in one context can be effective in other situations as well, because it saves all the safety testing that is necessary before a new drug is released to the market.

How Do They Work?

To talk about where massage therapy fits in the context of our clients’ medication use, we need to know a little bit about how medications work. This is called pharmacotherapeutics, pharmacokinetics, and pharmacodynamics. The video that accompanies this article will demonstrate how to read a complex drug guide and how these terms are used in that context. 

Pharmacotherapeutics (PT)

PT refers to what a medication is used for. In drug guides, this might be called “indications” or “uses.” As we saw in the discussion of classifications, many medications have multiple PTs.

Pharmacokinetics (PK)

Pharmacokinetics refers to how medications move through the body—from consumption, through metabolism, to excretion. The process of metabolism isn’t especially relevant for massage therapy at this point (unless someday we determine that receiving massage changes the rate or process of how a client processes a drug), but the way medications are administered and excreted may have some bearing on our choices.

Administration

There are four main ways drugs can enter the body to affect function: by mouth, by topical application, by mucous membranes, and by injection.

By Mouth

Most common medications are taken orally (or “per os”— by mouth). This is easy and convenient for many patients, but the substance has to undergo filtration and metabolism in the liver before it enters the general bloodstream. Whatever makes it that far is called the bioavailable fraction of the drug. This means a person’s digestive and liver function may influence how much of a medication they need to receive any benefit. Some drugs cannot withstand this process, and they degenerate before they are usable; this is why insulin cannot be taken orally. Because massage seems to boost digestive motility, our work may have an impact here.

Topical Application

In this context, we are referring to medications that are intended to enter the bloodstream, rather than substances like pain-relieving gels or creams that are meant for local impact only. In order to access the blood via the skin, drugs must be administered in high concentration, have duration of contact with an area of skin with hair shafts, and be soluble with a molecular weight that allows it to pass into the capillaries. Sometimes these medications are used with solvents to help carry them across the epidermis and into circulatory or lymphatic capillaries.

Topical applications have some advantages over orally taken doses of medications: They bypass the filtration of the liver for direct access to the bloodstream and lymphatic system, and they can be applied in multiple locations to avoid irritation.

From the point of view of massage therapists, however, topical applications of medications may carry some risks. If the dose is in the form of a patch, like nicotine or birth control patches, it is easy to identify and avoid (I suggest avoidance of several inches in every direction, because we don’t want to change the rate of uptake at the site). But some topical medications, especially hormone creams, may not have any visible signs. More than one massage therapist has asked me whether they were inadvertently dosed when working with clients who didn’t tell them about their estrogen or testosterone cream until after they had already touched the area.

Fortunately, the palms of the hands are among the least permeable parts of the body, and if our skin is intact—and we wash our hands frequently—our risk of significant exposure to medications in this way is minimal. Still, if we know our client has used a hormone cream or other topical application of a drug in some area, it is best to avoid it, so we don’t have unintended influence on the dosage or uptake.

Through Mucous Membranes

Some medications are inhaled, absorbed through the mucous membranes of the cheek or under the tongue, or absorbed as suppositories in the rectum or vagina. Like topically applied medications, this avoids filtration by the liver, giving almost instantaneous access of the drug to the circulatory system. Nitroglycerin sublingual tablets (Nitrostat) for chest pain are an example of this kind of fast action.

One of the challenges with drugs given by way of mucous membranes is that the uptake can be variable and unpredictable. This is why inhaled insulin didn’t work for most people: It is a drug that has to be given in the right dosage, at the right time, and this was too hard to predict when it was used as an inhalant.

By Injection

Injections of medications can happen in a few ways. Drugs can be pushed into the subcutaneous space (insulin is an example) or into the intramuscular space, like vaccines or antibiotics. In some situations, it is best for a drug to access the bloodstream immediately. This is done with an intravenous (IV) application. If this is an ongoing need, a patient may have a port or a peripherally inserted central catheter, or PICC line.

Injection sites are local contraindications for massage for a few hours at least. In the case of botulinum toxin (Botox), which is injected into the subdermis or intramuscularly, many physicians recommend waiting a few days before doing massage in that area.

Excretion

Most drugs are excreted through urine and feces, which typically happens within 48 hours of taking the dose. Some drugs, notably some types of chemotherapy, are excreted in sweat and sebum. MTs who specialize in working with cancer patients will need to know the protocols for clients who are dealing with this situation—that is an issue to discuss with their health-care team.

Pharmacodynamics (PD)

Pharmacodynamics refers to the action of the drug: what it does to its target cells and tissues. Medications use many strategies to achieve the goals of treatment, and more are in development all the time. Here are some of the most common pharmacodynamics, with examples of drugs that work in this way:

Cell membranes. Some drugs may act on cell membranes to limit or promote the passage of substances into or out of the cell. For example, metformin (Glucophage) makes cells more receptive to sugar.

Body fluids. Medications may alter the chemical properties of some fluids. For example, proton pump inhibitors (Prilosec, Prevacid) change the pH of stomach secretions.

Enzyme systems. Some drugs change the enzyme systems inside or outside cells. For example, selective serotonin reuptake inhibitors (Prozac, Zoloft, Paxil) alter the activity of enzymes that would normally disable neurotransmitters left in synaptic gaps in the brain.

Replication. Antibiotics prevent or inhibit replication of the targeted bacteria, and some kinds of chemotherapy and other cancer drugs interfere with the cell replication cycle.

Side Effects and How to Mitigate Them

A drug side effect is an unintended and often disagreeable effect of a medication. While often mild, temporary, and annoying, side effects can sometimes be severe. Very serious consequences of medication use are called adverse drug events, and they include things like allergic reactions, accidental overdoses, and dangerous drug interactions.

Massage therapy is most likely to have a direct interface with the medications our clients use in the context of side effects. Some side effects are just accepted as part of medication use, but some might prompt people to make an appointment for massage. Atorvastatin (Lipitor) is associated with muscle pain, for instance (a subject I covered in “Statin Use and Massage Therapy” in the January/February 2018 issue of Massage & Bodywork, page 40). Some drugs used for symptoms of perimenopause or birth control can cause headaches. And sometimes drugs simply cause a feeling of fatigue or low stamina—antihypertensives are especially likely to do this.

It can be appropriate to work with a client who wants relief from drug side effects, but it is important that we know what drugs they’re using, and why. And if the side effects have a profound, more-than-occasionally-annoying effect on a person’s quality of life, then it is appropriate to refer them back to their prescribing physician, who may be able to make some adjustments for a better result.

Shown above is a table of side effects related to some commonly used medications, and how massage therapy might be adjusted to mitigate them, bearing in mind that further accommodations may be needed, depending on the underlying conditions.

This table is by no means comprehensive, and your clients’ medications, side effects, and necessary accommodations may be quite different from what you find here.

This basic introduction to pharmacology is meant to provide enough guidance to make safe choices in the short run and to get more information in the longer run. It is not enough to ask, “What medications do you use?” We must follow that up with questions about why they use those medications, and what side effects are present—because those are the answers that will inform clinical decisions.

 Ruth Werner is a former massage therapist, a writer, and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology (available at booksofdiscovery.com), now in its seventh edition, which is used in massage schools worldwide. Werner is also the host of the podcast I Have a Client Who . . . on The ABMP Podcast Network. Werner is available at ruthwerner.com or wernerworkshops@ruthwerner.com.