Corticosteroids are steroid hormones made naturally by the body and are classified as either mineral corticoids or glucocorticoids. Artificial corticosteroids are used as medications. You might be familiar with the most commonly prescribed synthetic steroids which are triamcinolone, cortisone, prednisone, dexamethasone and methylprednisolone. Many of our clients may be undergoing some treatment which includes the use of steroids. (The common term 'steroids' used here should not be confused with the male hormone related steroid compounds that are used predominantly to build muscle mass.)

It is very important to do a thorough medication/medical intake evaluation. It is also important for you to be proactive in reading about and researching your client's conditions and medications so that you can customize the massage sessions appropriately. An excellent website for researching medications is www.drugs.com. Other websites that provide easy to understand information and offer insight are the Cleveland Clinic at my.clevelandclinic.org and the Mayo Clinic at www.mayoclinic.com and www.webmd.com. These are excellent sites to recommend to your clients to research their own conditions and medications. You can also find some great complimentary sites that are packed with helpful knowledge. In my practice, I have found that the more familiar a client is with their condition and medications, the more effectively they communicate with their healthcare providers.

Steroids are used to treat a variety of conditions and manage pain. Steroids work by decreasing inflammation and reducing the activity of the immune system. More specifically, steroids reduce the production of inflammatory chemicals in order to minimize tissue damage. Steroids also reduce the activity of the immune system by affecting the function of white blood cells. Another common use of steroids is in conjunction with chemotherapy. The primary benefits when used in cancer treatment include: reduced nausea associated with chemotherapy and radiation, kills some cancer cells and shrinks tumors as part of chemotherapy, and decreases swelling and reduces allergic reactions (before transfusions, for example). And since one of the side effects of steroid use is increased appetite and weight gain, this can also benefit the client undergoing traditional treatment for cancer. Additionally, they can excite the system so they can be effective fatigue fighters.

Let's take a look at some of the side effects and see how they might impact your massage session. Keep in mind that not all patients will develop side effects and the side effects will be different for each individual. The occurrence of side effects depends on the dose, the type of steroid given and the length of treatment. The following list includes the more common side effects of systemic steroid use given either through pill form or IV administration. These circulate through the blood stream. This is only a partial list. As already mentioned, the client may be experiencing wakefulness or agitation, nervousness or restlessness and increased appetite and weight gain. They may bruise easily, the skin may become thin, and they may develop streaks or red spots. They may experience changes in body fat distribution, water retention and swelling. Steroid use can also cause or worsen diabetes, increased blood pressure, cause cataracts or glaucoma, and blurred vision. Of particular interest to massage is possible muscle weakness, corticosteroid induced myopathy, and osteoporosis/osteonecrosis. We'll look at bone loss and muscle weakness in a minute.

Steroids can be administered locally in a variety of ways. Inhaled corticosteroids are often prescribed for asthma. They are used in lower doses to reduce inflammation in the airways. Corticosteroid nasal sprays are sometimes used to relieve allergy symptoms. Topical corticosteroids are rubbed on the skin, where they help relieve the itch and redness of inflammatory skin conditions such as eczema. Injected corticosteroids can be given to reduce or relieve the symptoms of rheumatoid arthritis, joint pain, plantar fasciitis and such. Typically, these cause fewer side effects than oral corticosteroids. When reviewing your client's list of medications, keep this in mind and think through the process. So, let's go back and look at some specific musculoskeletal issues that you need to be aware of.

"High-dose cortisone is the second most common cause of osteoporosis, and we currently have no real treatment for this serious side effect," says senior author Steven L. Teitelbaum, MD, Messing Professor of Pathology and Immunology. "Given how frequently these drugs are used to treat many different conditions, that's a major clinical problem." The femoral head is the most commonly affected area. Common sense tells you that if your client fits into this category, you must never use the deep pressure during the massage. One study, published in The Lancet medical journal in 2000, stated that high doses of inhaled steroids used by asthma patients caused significant loss in bone density. The key here is high dose versus low dose and the length of treatment. The study used patients on high doses for at least six years. Think it through. Look it up. Talk to your client.

Corticosteroids inhibit intestinal calcium absorption and increase urinary calcium excretion leading to bone resorption and bone loss. People taking oral steroids also double their risk for severe vitamin D deficiency, which can lead to further bone disease or muscle weakness. Researchers at Albert Einstein College of Medicine of Yeshiva University, in New York City, said in September 2011, steroids might increase levels of an enzyme that inactivates the vitamin, resulting in osteomalacia (softening of the bones), rickets (softening of bones in children) or clinical myopathy (muscle weakness). They recommended that physicians monitor vitamin D levels of patients being treated with oral steroids.

Corticosteroid induced myopathy is damage to the muscle fibers caused by treatment with corticosteroids, such as prednisone, cortisone, dexamethasone and fludrocortisone or overproduction of steroids associated with Cushing's disease. Myopathy causes changes in muscle fibers, including atrophy (shrinkage), lipid (fatty) deposits, necrotic (dead) areas and increased interstitial (connective) tissue between fibers. You may have severe damage to the muscles while the muscles appear normal in size. This happens because the connective tissue increases in the space surrounding the muscle fibers so no noticeable difference in the anatomy is obvious. Everything "looks" normal. However, these clients will experience increasing intolerance to exercise because the muscles start to weaken with use and pain increases. The muscles most affected are those in the arms and legs and the pelvis (hips). Weakness usually starts in the proximal (upper) portion of the muscle and progresses to the distal (bottom) portion. You may have increased difficulty standing, walking up stairs and reaching upward.

The potential impact on bone, muscle and skin with high dose steroid use should send up a red flag in your massage therapy brain. Additionally, because of the possible fluid changes in the body, the circulatory system could be overloaded so try to minimize the movement of fluids with gentle work unless you are trained to specifically work with this. Refer them to a massage specialist or get permission (in writing) from their doctor.

In summary, I think it's safe to say that gentle work is the best way to go with clients on steroids. The exception to this may be in working on the feet. The feet are made to take a pounding like nothing else in the body. The small muscles in a tendon rich environment are designed to withstand pressure that our larger muscles are not designed to do. So, even if your client is undergoing chemotherapy and suffering with chemotherapy induced peripheral neuropathy, the deeper work on the feet to address this issue is generally acceptable. Another (and additional) option for these clients might be stretching. One therapist I spoke with suggests beginning Tai Chi to all of her oncology clients. I think that's a great suggestion. Keep up the good work!