Learning about prescription drugs and over the counter (OTC) medications can be overwhelming and confusing to massage therapy students and new therapists studying for the MBLEx. I created this post to help you understand this topic a little better as you prepare for the massage licensing exam.
Massage therapy can have strong physiological effects on many systems of the body including the circulatory, integumentary, muscular and lymphatic systems. For this reason, massage therapists need to understand how this therapeutic effect can impact a client’s current medical conditions. And how massage treatment may interact with any medications that the client may be taking.
Many massage therapy students preparing for the MBLEx are wondering:
What medications do I need to know for the MBLEx? Massage therapists should know the basic classes of medications and the most common drugs that increase the patient’s risk of injury when combined with massage or bodywork treatments. This includes, but is not limited to, over-the-counter and prescription analgesics, anti-inflammatory drugs, muscle relaxers, antibiotics, diabetes management drugs, anticoagulants, antidepressants, and anxiolytics.
As stated by the FSMTB, the questions on the MBLEx are focused on what entry-level massage therapists need to know in order to safely provide massage and bodywork treatment for their clients. You aren’t expected to memorize hundreds of medications and their side effects in order to pass the MBLEx. Just know the medications most likely to an cause adverse reaction if combined with massage therapy.
Why it’s important for massage therapists to know medications
Medications can potentially impact massage treatments due to their combined effect on the body. Prescription and over-the-counter (OTC) drugs may affect different aspects of treatment planning including:
- Scheduling of the treatment
- Duration of treatment
- Techniques and amount of pressure
Medications may alter normal pain response and prevent the client from being able to provide accurate feedback regarding pressure and intensity of treatment. Clients must be able to accurately perceive any discomfort in order to inform their therapist and prevent injury from the treatment.
For clients taking pain medication for minor conditions, it is best to schedule the medication immediately before, or soon after the massage treatment. This way the levels of medication in their system is at its lowest point.
According to a survey published in May 2019, 45.8% of the US population used prescription drugs in the 30 days prior to the survey. Prescription drug use increases with age, with over 85% of adults over 60 years of age taking at least 1 medication.
This survey goes on to report that antidepressants (11.4%), analgesics (8.3%), and lipid-lowering drugs (7.5%) are the most commonly used medication for adults aged 20-59. And for adults 60 years or older, the most common are lipid-lowering drugs (46.3%), beta-blockers (24.8%), and antidiabetic drugs (22.6).
Knowing what medications your client is on will also give you insight into what medical conditions that your client may be currently dealing with.
It is often the underlying medical diagnosis, not the drug itself, that is the concern. For example, massage may not be contraindicated because of the antibiotic. However the systemic infection that the antibiotic is treating will likely be a contraindication.
Likewise, a client on Fosamax will need a massage treatment with less pressure, not because of the medication, but because of the underlying osteoporosis.
Classes of medications
A medication class is a group of medications that are similar in some way. This similarity could be based on:
- Its therapeutic use (conditions the drug treats)
- The biochemical reaction that the drug causes (“mechanism of action”)
- How the body responds to the drug (“mode of action”)
- The drug’s chemical structure
It is important to understand that a drug’s therapeutic class does not always align with its primary indication. For example, drugs that are used to treat high blood pressure can span multiple therapeutic classes (i.e., beta-blockers, diuretics, ACE inhibitors, and calcium channel blockers).
Inversely, a drug in one class may be used to treat multiple health conditions. For example, Gabapentin (Neurontin) is an anti-epileptic (anticonvulsant) drug that is typically used to relieve seizures. However it is also used to to treat multiple other conditions including muscle spasticity and nerve pain, such as with peripheral neuropathy or shingles.
Another example is levothyroxine has been approved to treat hypothyroidism, but is also sometimes used to treat depression.
There are many different ways that drugs are classified and categorized, depending on which agency is classifying the medications. In the US, the United States Pharmacopeia (USP) has categorized drugs into 49 different therapeutic classes. These are very broad categories and there are thousands of different sub-classes.
MBLEx Tip: When you are preparing for the MBLEx, keep it simple. Study what you need to know for the massage exam and don’t feel like you have to memorize hundreds of medications, how they work, and side effects.
Instead, focus your study of medications on those that are most likely to affect a massage treatment, and therefore are most likely to be on the massage exam.
Once you’re a practicing massage therapist, you can always look the medications up online or keep a current reference book on hand.
The classes of medications that most likely and commonly affect a massage therapists plan of treatment are arguably pain medications and blood thinning medications. Medications that cause dizziness or orthostatic hypotension are also a concern since they can increase the client’s risk of falling when getting up from the table.
Major classes of medications you should be familiar with for the MBLEx:
- Analgesics (including opioid and non-opioid)
- Anti-inflammatory (including corticosteroids and NSAIDs)
- Anxiolytic (anti-anxiety)
- Blood glucose regulators (insulin, glucagon, diabetes management drugs)
- Blood regulators (anticoagulants)
- Cardiovascular agents (beta blockers, ACE inhibitors, diuretics)
- Skeletal muscle relaxants
It is important for massage therapists preparing for the MBLEx to have at least a basic understanding of how these classes of medications can interact with massage or bodywork.
Medications that massage therapists should know for the MBLEx
The following medications were included in this list because of how frequently they are prescribed, and because they may require a massage therapist to modify the treatment plan or take additional precautions.
- Other names or similar drugs: cortisone, hydrocortisone
- Description and Uses: Prednisone is a corticosteroid that is prescribed for a wide range of conditions including inflammatory disease, auto-immune disease, kidney disease, chronic pain, arthritis, breathing problems, severe allergies, cancer, and skin diseases.
- Effects on body: Prednisone can cause hyperglycemia, swelling, and thinning of the skin. Long-term use of corticosteroids can cause osteoporosis.
- Potential interaction with massage: Gentle massage is recommended due to fragile skin and easy bruising. Also avoid techniques that shift fluid balance.
- Other names or similar drugs: Advil, Motrin, Aleve
- Description and Uses: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used to treat various conditions including muscle aches, headache, pain related to arthritis, menstrual cramps, fever, and pain related to cold or flu.
- Effects on body: reduced pain and inflammation
- Potential interaction with massage: Clients may not be able to provide accurate feedback about comfort level during the massage. This could result in bruising or other mechanical injury. They may also me more susceptible to burns if heat treatments are used.
- Other names or similar drugs: Heparin, Warfarin
- Description and Uses: Coumadin is an anticoagulant (blood thinner) used to treat blood clots such as deep vein thrombosis (DVT) or pulmonary embolism (PE). These drugs are also used to prevent new clots from forming, and are frequently prescribed due to atrial fibrillation, after surgeries like heart valve replacement or orthopedic surgeries.
- Effects on body: thins the blood by decreasing the amount of clotting proteins in the blood
- Potential interaction with massage: Clients on blood thinners have an increased risk of bleeding and bruising.
- Other names or similar drugs: Hydrochlorothiazide, Furosemide, Aldactone
- Description and Uses: These are diuretics (“water pills”) that help your body to get rid of extra water and salt, in order to lower blood pressure and take pressure off the heart. Diseases of the heart, liver or kidneys can cause a build up of edema, which leads to high blood pressure, and increases the risk of stroke and heart attack.
- Effects on body: Diuretics such as Lasix will cause fluid loss, and can have side effects of lightheadedness, muscle cramps, dehydration, weakness and fainting.
- Potential interaction with massage: can cause orthostatic hypotension, putting clients at risk for falling when getting up from the table.
- Other names or similar drugs: Tylenol, it is found in many OTC combinations. Aspirin is in the same class of drugs.
- Description and Uses: Acetaminophen is a non-opioid analgesic (pain reliever) and fever reducer. It is used to treat mild to moderate pain in such conditions as headaches, muscle ache, minor injuries, and arthritis.
- Effects on body: It is a weak analgesic but does not possess anti-inflammatory properties like NSAIDs do.
- Potential interaction with massage: Due to decreased sensations of pain, clients may not be able to provide accurate feedback about intensity of massage and bodywork treatments.
- Other names or similar drugs: cyclobenzaprine, Soma, Baclofen, Skelaxin, Zanaflex, Valium (diazepam)
- Description and Uses: These are muscle relaxants that are used to treat muscle spasms, cramps, or spasticity. Flexeril is commonly indicated for acute pain related to muscle injuries, strains or sprains. fibromyalgia
- Effects on body: Flexeril works in the central nervous system by blocking nerve impulses that are sent to your brain. It also influences motor neurons of the brainstem and spinal cord to relieve spasms.
- Potential interaction with massage: dizziness and drowsiness. It may impair the client’s ability to provide accurate feedback about treatment intensity.
- Other names or similar drugs: Zestril, Prinivil, ramipril
- Description and Uses: Lisinopril is an ACE inhibitor mainly used to treat certain heart and kidney conditions. hypertension (lowering blood pressure)
- Effects on body: ACE inhibitors like lisinopril ultimately cause the blood vessels to relax, which decreased blood pressure and kidney pressure.
- Potential interaction with massage: Lisinopril can cause a sudden drop in blood pressure upon sitting up or standing up (orthostatic BP), which can increase the client’s risk for falling when getting up from the table.
- Other names or similar drugs: oxycodone, fentanyl, morphine, opiates, opioid analgesics
- Description and Uses: Hydrocodone is a narcotic analgesic used to provide pain relief for moderate to sever acute or chronic pain. They are commonly prescribed after surgery, or for palliative of end-of-life care.
- Effects on body: Narcotic analgesics work by binding to opioid receptors.
- Potential interaction with massage: Narcotic analgesics will impair the client’s ability to provide accurate feedback about treatment intensity. Client’s on these medications may also need to be cleared by their physician for massage, due to increased risk related to underlying medical condition.
- Other names or similar drugs: Clopidogrel
- Description and Uses: Plavix us used to prevent stroke and heart attacks in persons with heart disease, those who have had a recent stroke or heart attack, and people with blood circulation problems such as peripheral vascular disease.
- Effects on body: Plavix works by blocking platelets from sticking together and forming harmful clots.
- Potential interaction with massage: Increased risk of bruising and bleeding.
Remember that medications may be delivered through different routes, including orally, by injection, topical application, inhalation, through transdermal patches, and by implanted devices.
Avoid massaging on or around administration sites. This includes injection sites, skin patches, and where topical medications have been applied. Also avoid massaging around implanted devices such as an insulin pump or pain pump.
How to talk to your massage client about their medications
The best time to gather information about any medications that a client is taking is at the initial client assessment.
Some clients may not understand why disclosing information about their medications is important, especially if it is a spa setting or they only want a massage for relaxation. So it is important to explain to the client that since massage therapy can have a strong affect on the body, this can cause adverse reactions for people on certain medications. It can help to give them some examples of specific medication classes that could impact their treatment plan.
You could also include this explanation in writing on the intake form, about why it is important to list their medications.
However, even after explaining why listing medications is important, some clients will choose not to divulge that information. Ultimately we have to take the client’s at their word on this. Either way, be sure to have clients sign any intake documentation including a consent form stating that they understand the risks.
It is also best practice to inquire about any health or medication changes at each follow-up appointment.
Stay in your scope of practice
It is not within the massage therapist scope of practice (in any state) to give their clients advice about medications. Doing so can put your client (and your license) at risk.
MBLEx Tip: You are very likely to see some version of the statement above on the MBLEx.
It is also not within the scope of practice for massage therapists (in most states) to give advice on nutrition, supplements or herbs. This is because of the potential interactions of certain foods, herbs or supplements with medications that the client may be taking, or affects on underlying medical conditions.
Only properly trained and licensed nutritionists, physicians or other relevant health professionals should give advice regarding these subjects, as long as it is within their scope of practice.
Even with the best intent, wrong advice can cause harm.
It is also inappropriate for massage therapists to express their own personal beliefs and opinions about pharmaceuticals. A massage therapist who tells their client about how much they dislike “Big Pharma” may influence the client to alter or discontinue their prescribed medications without their physician’s knowledge. This could harm the patient because there are many drugs which cannot safely be stopped without tapering down and careful monitoring.
Don’t get me wrong. Like most people into healthy lifestyles, I think that many people are overmedicated. And I think there are often better options than prescribing more medications. But that is my opinion, and offering medical advice regarding medications is out of my scope of practice, so I don’t do it!
The only recommendation regarding medications that I feel comfortable and qualified, and am legally allowed to give to clients, is to suggest that when they see their primary care physician (PCP) or specialists, to ask if there are any medications they are currently taking, that they can safely cut back on, or discontinue.
How to check for possible adverse effects
All medical professionals from medical doctors, nurses, physical therapists, and even pharmacists, rely on medical references to look up medications. No one can remember them all.
It is important to have at least a basic knowledge of common classes of medication, and how they can impact the client’s response to therapeutic massage and bodywork treatments. This is important not only to pass the MBLEx, but to be able to provide safe massage treatments for your clients.
Once you’re a practicing therapist, however, it is a good idea to have convenient, accurate and up-to-date references where you can check for any precautions or potential adverse reactions that massage could cause.
Here are some reputable online resources for medical information:
- nlm.nih.gov (Medline Plus)
What if you’re still not sure about a possible adverse reaction?
You may still have a legitimate concern that massage may be locally or systemically contraindicated because your client is taking a certain medication. If this is the case, it is best to be conservative in your massage treatment approach.
At this point you must use your clinical judgement, remembering the Hippocratic Oath of ethics to “first do no harm”. This may mean postponing the massage treatment, modifying your treatment plan or technique, or just avoiding a specific area of the body.
Open communication with the client is important. Express your concerns. You can also contact the client’s physician for clearance to proceed with intervention. If the physician advises you to withhold treatment you should adhere to this. If the client’s physician says that it is ok to proceed, you must still use your clinical judgement about your treatments because ultimately you are the one responsible for the treatment you provide.
Make it a habit of two things: to help; or at least to do no harm.Hippocrates