Massage
& Medications
Principles
for an Informed Practice
By Randal
S. Persad
Clients who
visit massage therapy clinics for relaxation, or seek out massage in settings
like spas or fitness centers, are often taking drugs for heart problems,
arthritis, cancer, diabetes, AIDS, depression, chronic pain and so on. The fact
that the focus of the treatment may be stress reduction or routine self-care
does not mean the interaction between the client's medication and the massage
therapy given is a non-issue. This is also true about treatment modalities that
might be considered "light," like lymphatic drainage, or more
energy-focused, like craniosacral therapy. Since there is a drug in the client's
body, the practitioner needs to have basic information about how it may impact
the client's responses to the provided treatment about to be given.
Both pharmacy
and massage therapy, although very different disciplines, attempt to create
physiologic and psychological changes important to the achievement of better
health and quality of life. All medications affect the normal responses of the
body in some way. While some of these effects are not relevant to massage
practice, in many cases, the combined physiological results enhance or alter the
impact of massage therapy modalities. At times, the outcome can be adverse.For
example:
• Centrally
acting skeletal muscle relaxants (e.g., cyclobenzaprine) depress various parts
of the central nervous system. This can alter the normal protective stretch
reflexes in skeletal muscles so that there is potential for damage from manual
techniques.
•Phenothiazines (e.g., trifluoperazine) are used for their anti-psychotic
properties. They often alter the temperature-regulating mechanisms of the body,
creating an important hydrotherapy concern.
•Corticosteroids (e.g., dexamethasone) are a group of drugs widely used in
medicine to control pain, inflammation and immune responses. These drugs are
also known to weaken connective tissues, including skin, fascia, ligaments and
muscle.
The general
population is increasingly combining allopathic medicine (using drugs to treat a
condition and/or alleviate symptoms) and non-drug therapies such as massage.
This combining of therapies by the American public was first documented in a
study published in 1993.1 The data indicated that 83% of individuals interviewed saw both
their medical doctor and providers of "unconventional" medicine2
in their search for better health, even when they had serious medical
conditions. The study additionally found that 72% did not inform their physician
they were receiving these other therapies while under medical care. Whatever the
reasons for this are, it speaks to the need for practitioners of complementary
health care methods to have independent awareness of the implications of
combining their treatments with common allopathic modalities.
When a client
reports: "My doctor has prescribed muscle relaxants for me," or
"I have been taking a painkiller since the accident," or "I got a
steroid shot for the bursitis," the massage therapist needs to understand
the significance of these statements as they relate to massage treatment
planning. The practitioner is responsible for both the effectiveness and the
safety of the therapy provided.
To do so,
massage therapists should have a basic understanding of the actions and effects
of commonly used drugs, and the ability to research the effects of other
medications encountered; the knowledge of how massage affects the body's
physiology; and the ability to apply this knowledge to varying client
presentations.
Guidelines for
Assessment
Most clients have a limited ability to distinguish the multitude of factors that
can contribute to their symptoms when presenting a complaint. This is especially
likely if the complaints are related to medication effects. If the massage
therapist is unaware of the mechanisms of action of medications and the
potential impact of side effects, interpretation of the client's symptom picture
and assessment findings can lead to misleading conclusions. This, in turn, can
result in development and administration of ineffective or harmful treatment
plans and poor client recovery. A client's medications have the potential to
alter the results of the massage therapist's assessment of his or her case.
Therefore, listening to the client characterize a problem is an especially
important part of conducting an assessment. With experience, the practitioner
can often form an accurate clinical impression just by listening to the client's
description of his or her complaint. This awareness can help the practitioner
anticipate the involvement of medications in some cases, or to follow through
appropriately if massage treatment does not have the expected result in
addressing the complaint.
In addition to
listening, it can be useful to incorporate a specific form to document each
client's medications, remedies and supplements. The reasons for having a
medication case history form include having a clear record of which drugs and
other substances are being taken and why, having a reference for sorting client
complaints in light of potential relationship to medication use and having a
quick reference for treatment planning.
To enhance the
usefulness of the information gathered on the medication intake form, therapists
need to consider the impact when more than one medication is prescribed for the
treatment of a singe condition, a single medication is used in the management of
more than one condition, when one or more of the medications is a long-term
prescription, and when the client is taking a mix of traditional and
non-traditional substances.
The first step
in the assessment process is observation, or the "looking phase,"
which begins when the therapist greets the client. This part of the assessment
is an important source of information about the client's health and includes
observing facial expression, gait and movement patterns, skin color and health,
edema, physical deformity, standing and sitting posture, and limb size and
shape.
For example, a
client on long-term use of a calcium channel blocker medication will be
predisposed to developing an altered gait pattern. This is because accumulation
of edema in the feet and ankles is often associated with this group of drugs.
The massage therapist who is unaware of this side effect may interpret the
altered gait as caused by a hip or lower back disorder and plan a treatment to
focus on these areas. The edema may be perceived as secondary rather than
primary in the etiology of the problem. To resolve the altered gait, and any
secondary complaints of the client such as hip and lower back pain, the edema in
the feet and ankles must be treated. As well, a physician needs to be informed
of the degree to which the medication is affecting the client's musculoskeletal
system.
The massage
therapist must also be aware of palpation. Changes in tissue health, muscle tone
(hypo- or hypertonicity), skin temperature and moisture, fascial mobility,
myofascial trigger points, and tissue fluid levels are all palpable. For
example, medications such as muscle relaxants and other central nervous system
depressants will alter the tone of the skeletal muscles so that they feel
"loose" and are too easily overstretched. And, long-term use of oral
corticosteroids will lead to breakdown of connective tissues including the skin,
muscle and lymphatic tissues. If edema is present, the skin will often feel
fragile, and muscles tend to be soft and hypotonic.
Finally, during
the testing portion of the assessment, the client is asked to perform certain
movements and/or the therapist moves the client's body through special tests
that target the structures being assessed. The test findings help determine
which tissue structures are involved, and to what degree, in the presenting
complaint. Medications such as anti-inflammatories and narcotic analgesics alter
the client's pain perception. When asked to do active movements, the client may
be able to perform normal or near-normal range of motion without showing signs
of pain and discomfort that would accurately reflect the stresses being applied
to the tissues. Passive movement results are likely to be skewed in a similar
fashion.
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Examples
why a massage practitioner needs to know basic information about drug
effects and interactions: 2. A
client with a sore shoulder is taking a pain-relieving drug, such as
aspirin or ibuprofen, and also seeks out massage treatment. The client
requests "deep work" to get to the root of the problem, which is
a combination of tendinitis and old scar tissue. The therapist complies
and gives a rigorous deep treatment. The next day the client is very
bruised and in much worse pain. If the therapist had been aware that
aspirin and ibuprofen have anticoagulant properties, as well as reducing
the ability to give accurate feedback about how painful a technique is, it
would have been clear that the "deep work" approach was not
indicated at that time. |
Guidelines for
Treatment Planning
Treatment planning involves being familiar with the general health of the
client, having a good understanding of the nature and progression of the
presenting condition(s), and designing a safe and effective approach to
achieving the massage treatment goals. However, providing safe and effective
treatment compatible with a client's medications can sometimes be challenging
for the practitioner.
For instance,
the following excerpt contains information about the anticonvulsant drug
carbamazepine (used in the treatment of epilepsy).3
Let's look at the drug profile and relate the information to massage treatment
planning.
The
absorption of carbamazepine in man is relatively slow. When taken in a single
oral dose, the carbamazepine tablets and chewable tablets yield peak plasma
concentrations of unchanged carbamazepine within 4-24 hours. Only 2%-3% of the
dose, whether given singly or repeatedly, is excreted in the urine in unchanged
form. The primary metabolite is the pharmacologically active 10, 11-epoxide.
After repeated doses, the elimination half-life of unchanged carbamazepine is
16-24 hours, depending on the duration of the medication.
Because the
onset of potentially serious blood dyscrasias (abnormal conditions of blood
cells) may be rapid, patients should be made aware of early toxic signs and
symptoms of a potential hematological problem, as well as symptoms of
dermatological or hepatic reactions.
If reactions
such as fever, sore throat, rash, ulcers in the mouth, easy bruising, petechial
or purpuric hemorrhage (purplish red spots caused by the release into the skin
of a very small quantity of blood from a capillary) appear, the patient should
be advised to contact his or her physician immediately.
Other
adverse reactions include: skin sensitivity reactions and rashes,
photosensitivity, hypertension or hypotension, nausea, vomiting and aggressive
behavior.
How would a
massage therapist use the above information and relate it to massage treatment?
• Since carbamazepine is used in the treatment of epilepsy, the stability of
the client's condition is of concern. Treatments should be scheduled when peak
levels of the drug are expected - according to the drug profile, this occurs at
least four hours after taking a dose.
• Good clinical practice would include taking a blood pressure reading at the
start of each treatment. If you observe significant changes, inform the client
and suggest a follow-up visit to the physician.
• The health and function of the liver and kidneys are extremely important for
maintenance of therapeutic levels of medications in the blood. The long
half-life of this drug, and the fact that the primary metabolite is
pharmacologically active, suggest the client can quickly develop adverse effects
if normal elimination processes are compromised by poor organ health. Complaints
such as fever, and reddish or purplish bruises as mentioned in the drug profile,
are early indications of drug toxicity. The practitioner will want to stay alert
to the symptoms and complaints of the client. When there are indicators of drug
toxicity present, massage treatments are contraindicated until the client is
evaluated and cleared by the attending physician.
Obviously, it
is beyond the massage therapist's scope of practice to tell clients when to take
their medications. However, by adjusting when massage therapy is given, the
practitioner can work to best coincide treatment with the bioavailability cycles
of drug use.
Another
important consideration when determining treatment planning is the medical
stability of the client. A client whose condition necessitates long-term drug
use usually requires a certain medication level in the blood to ensure the
condition remains stable. For example, an insulin-dependent diabetic must have
regular doses of insulin to maintain acceptable levels of glucose in the blood,
or a client being treated for a chronic pain syndrome requires pain medication
for physical and emotional stability.
Treatment
planning must take into account the circulatory and neural effects of massage
therapy which may tend toward destabilizing this type of client. In addition to
judicious treatment modification, the practitioner should consider scheduling
treatment sessions at a medication-appropriate time after the client's scheduled
dosage. The purpose is to ensure maximal bioavailability of the medication, and
therefore better stability of the client during and after the treatment.
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All medications affect the normal responses of the body in some
way. While some of these effects are not relevant to massage, the combined
physiological results can alter, often adversely, the impact of many
modalities. |
Massage
therapists should also consider client feedback implications. Drugs such as
non-steroidal anti-inflammatories, narcotic analgesics and central nervous
system depressants can alter a client's ability to give accurate feedback about
the comfort of techniques and modalities used during massage treatment. These
medications alter normal pain responses which warn of potential tissue injury.
Techniques or modalities that would normally cause some discomfort become more
tolerable than they should.
For clients
taking medications short-term for minor conditions, recommended treatment
scheduling is just before or soon after the medication dose. With lower
bloodstream bioavailability of the drug, the client is likely to give more
accurate feedback about the techniques and modalities used. However, the massage
therapist should still be cautious since the drug's onset of action can mask
symptoms of overtreatment. If unsure about how to judge the ideal timing of a
massage treatment for tissue safety, the therapist is encouraged to discuss this
concern with the client and/or the attending physician.
The Variable
Effects
Drugs can require adapting/shortening the massage treatment, so it is important
to consider the energy level of the client. Fatigue is a common side effect of
many medications, including hypertension medications, anti-anxiety drugs and
many antidepressants. In this case, massage therapy may cause even more fatigue,
and a shorter, more specific treatment design is needed. The client should be
asked to self-monitor during and after treatments for decreased energy or other
adverse effects, so the massage therapist can evolve a treatment design most
suited to the circumstance.
It's also
important to consider the emotional stability of the client. Long-term use of
some drugs, for example corticosteroids, is associated with mood fluctuations;
depression and anxiety are side effects of many medications. It is possible with
the additional physical/emotional effects of massage therapy, some clients may
feel emotionally volatile or overwhelmed, and this may warrant ending the
treatment early or planning for shorter sessions. Discuss this possibility with
the client in advance and together develop a plan of action.
Drugs can also
influence the selection of manual techniques. Let's look at some examples that
give rise to general guidelines:
Some Drugs
Alter Blood Clotting Mechanisms - Clients will be predisposed to bruising when
taking medications that alter the normal blood-clotting process. Examples
include anticoagulants, platelet inhibitors, aspirin and other non-steroidal
anti-inflammatory drugs.
Massage
techniques like muscle stripping, deep kneading, ischernic compressions (for
trigger point therapy) and cross-fiber frictions must be modified or avoided.
These techniques, when used on normal, healthy connective tissue to promote good
fiber alignment, often produce a mild inflammatory response easily resolved.
However, when the client is taking a medication with anticoagulant properties,
they can result in excessive bruising and inflammation.
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Hydrotherapy
and Pain Medication Interactions With use
of drugs that depress the central nervous system, like the skeletal muscle
relaxants and narcotic analgesics, systemic hydrotherapy treatments such
as saunas, whirlpool baths, herbal baths and medicated steams are not
recommended. The effects of the medications in combination with
generalized vasodilation from the treatment can lead to adverse effects
like dizziness, fainting, disorientation, confusion and edema of the
extremities. Be
observant with clients who are taking corticosteroids long term. Get a
sense of their general constitutional strength and the acuity of their
reactions to hot and cold. Prolonged
topical use of corticosteroids not only causes changes in skin
sensitivity, but can also affect the reaction of the local blood vessels
to hot and cold. Cutaneous blood vessels may spasm when exposed to even
mild temperature differences. |
Some Drugs
Alter Protective Responses - Several medications, including centrally acting muscle
relaxants, narcotic analgesics and anti-anxiety drugs, depress nervous system
reactions to sensory feedback from the stretch and tension receptors in muscle
and joint tissues. Firing from these sensory organs (muscle spindle, golgi
tendon organ, joint capsule and ligament receptors) may not elicit expected
responses to techniques that place stress or stretch on them. Massage therapists
tend to rely on such responses to determine when the pressure is deep enough or
a stretch is being applied optimally. When the tissue does not tighten as a
signal, manual techniques can inadvertently be applied too aggressively and
tissue damage caused. Techniques such as aggressive contract-relax stretching
and deep tissue work must be eliminated from the treatment plan, or used
cautiously.
While the usual
effect is to reduce the potency of protective reflexes, in some cases
overreactions can occur, leading to muscle spasm and reflex muscle guarding.
Some Drugs
Compromise Tissue Integrity - The corticosteroids in particular, especially when used
long term, cause atrophy and weakening of skin, ligaments, joint capsules,
bones, muscles and their tendons. When injected into joints for arthritic
conditions, they can induce breakdown of articular cartilage. Any massage
approaches that involve placing direct pressure or stress on tissue structures
will need to be employed carefully. Techniques such as rib springing, heavy
tapotement, passive forced stretching, muscle stripping, deep kneading,
frictions and joint mobilization should be significantly modified or avoided. Be
particularly careful with clients who are at risk for developing osteoporosis,
for example post-menopausal women and the elderly.
Normal health,
function and sensitivity of the skin are also compromised by prolonged topical
corticosteroid use. Skin rolling, frictions and wringing techniques can result
in bruising and inflammation of the subcutaneous tissues.
The therapist
should note that the conditions caused by such medication use will also impair
repair processes in body tissues, resulting in healing time frames that are
often longer than the "norm" and prolonged tissue fragility after
injury.
Some Drugs
Mask Pain Responses - Since assessment results can be compromised in the absence of
normal pain sensation, the test findings of clients using anti-inflammatories or
analgesics, either orally or topically, can make their tissues appear more
healthy and resilient than they truly are. The unaware practitioner may plan to
use more aggressive treatment techniques than is appropriate. It is important to
rely less on client feedback and more on observation and palpation, as well as
on medical advice as needed.
Some Drugs
Can Alter a Client's Cooperativeness - Various drugs, especially those that depress
the central nervous system (like the narcotic analgesics and anti-anxiety
agents), can make a client less communicative and seemingly indifferent to
supplying information in a complete way, either during case history taking or in
the course of treatment. The therapist will often need to spend more time and
take a determined approach, asking specific questions and making sure feedback
is frequently solicited.
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Quick
Guide to Working with Clients Who Are Taking Pain/Inflammation Medications
1.
Client Position and Comfort: Because of the nature of the condition
and/or medication effects, the client may not be able to reflect
accurately on the comfort and safety of delicate body tissues. The
practitioner must pay particular attention to position choices and
transfers. Swollen tissues need to be well-supported and elevated to
encourage drainage. Use pillows and other supports to ensure any
vulnerable body parts are not compromised. 2.
Tissue Health: Pay particular attention to the health and integrity
of the skin and underlying connective tissues. With longstanding or
chronic conditions, tissues are generally more fragile, tend to have
reduced or otherwise altered sensitivity, and can be more easily injured
from normal use of manual techniques. 3.
Systemic Health: Pain and inflammation can be a part of the symptom
picture of a systemic disorder. Familiarize yourself with the condition
and the specific clinical issues it presents. Evaluate the health of
systems like the cardiovascular system, which is usually affected by
generalized conditions. Pain and inflammation rarely present as unique or
independent systems - the practitioner must consider the underlying causes
and design the treatment approach accordingly. 4.
Effects of Touch: In most cases, professional touch in an
appropriately designed treatment approach will help reduce pain. However,
it is important to realize this is not always true. For individuals in
severe pain, sometimes being touched causes overload and results in more
distress and discomfort. This can change from day to day - the
practitioner has to be understanding and flexible. |
Pain and
Inflammation
The most commonly consumed, over-the-counter (OTC) preparations in the United
States are non-steroidal anti-inflammatory drugs. This group includes aspirin
and acetaminophen. In Canada, 1996 sales of OTC analgesics are estimated to have
been $197.8 million. Extrapolating to the U.S. market, sales figures of
approximately 10 times this amount are likely.
The estimated
annual cost associated with toxicity of these drugs is about $1.35 billion.
These drugs are also frequently taken alongside of other medications. Given the
widespread use and ease of availability of these drugs, massage therapists will
be treating an increasing number of clients who are using these medications for
pain and inflammation.
Below are some
guidelines to follow when addressing massage and medications associated with
pain and inflammation:
• It is important to always keep in mind that the purpose of these medications
is to relieve pain. Client feedback, although important to solicit and consider,
may be unreliable. The massage therapist must assume more responsibility than is
ordinarily the case for determining what treatment approaches are safe and
appropriate.
• Make sure you are aware of all the medications the client is taking, whether
prescription or OTC. Keep in mind drugs for managing pain and inflammation are
addressing symptoms. Especially when the cause is a systemic condition, various
other medications may also be employed and will need to be taken into account in
treatment planning. Be alert to the fact that multiple medication use can
predispose to a higher incidence of adverse effects.
• Schedule treatments around medication taking to maximize the accuracy of the
client's feedback and to optimize medical stability.
• Nausea and vomiting are potential side effects of these medications. Such
episodes can leave the client feeling weak and fatigued. Postponing the session
or giving a shorter, more specific treatment may be required.
• Dizziness, drowsiness and postural hypotension are also common side effects.
These can be heightened by massage. Ask your client about post-treatment
reactions - future treatments may need to be shortened or less intense. Always
instruct the client to sit up slowly and stay seated on the massage table for a
minute or so before standing up.
• Clients taking narcotic analgesics and corticosteroids often experience mood
changes and may be less communicative or responsive. The therapist may notice
the client is less cooperative, or seems disinterested in responding in a
meaningful or thorough fashion to requests for information or feedback. It can
be necessary to exercise a bit more professional assertiveness.
• Some clients will experience skin irritations. Ensure proper positioning,
and keep in mind that local massage is contraindicated until the reaction has
subsided.
• Topically administered pain and anti-inflammatory medications act in a
variety of ways on the local circulation and superficial nerves to relieve pain
and stiffness. They tend to compromise local sensation. If on-site work is
otherwise appropriate, exercise caution and modify depth of pressure when
working on tissues being influenced by such topical applications.
Here are some
specific guidelines to incorporate when working with pain and inflammation
medications:
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - These drugs have
both analgesic and anticoagulant properties. Clients may be unable to give
accurate feedback about technique pressures and will be more susceptible to
bruising if treated too aggressively. Be alert to complaints of gastrointestinal
pain and discomfort. The NSAIDs can cause ulcers and GI tract bleeding, both of
which can become life-threatening if not addressed medically. If the client has
been diagnosed and is being treated for GI side effects, abdominal massage and
hydrotherapy are contraindicated until the condition has resolved.
• Muscle Relaxants and Narcotic Analgesics - Muscle relaxants and
narcotic analgesics depress neural responses. Stretching techniques should be
avoided or applied cautiously because sensory feedback from muscular stretch and
tension receptors may be compromised. On palpation, the muscles - whose role it
is to protect themselves and their local tissues - will feel hypotonic.
Constipation is a common side effect of the narcotic analgesics. The decreased
intestinal motility is not greatly influenced by massage techniques. Prolonged
constipation or bowel restriction must be carefully monitored by a physician.
• Corticosteroids - The catabolic activity of the corticosteroids,
especially with long-term use, can impair tissue strength, resilience and
sensitivity. Skin integrity may be reduced. The body tissues are more easily
damaged by pressure and stretch. Massage techniques that place stress on the
muscles, bones and joints of the body must be avoided or modified. Examples
include rib springing, heavy tapotement and passive overpressure. Remember that
healing times may be longer than expected, and tissue repair may not be of the
best quality. Be particularly careful with clients who are at risk for
developing osteoporosis, like postmenopausal women and the elderly.
The
corticosteroids have immunosuppressant effects and can make a client more
susceptible to infection or communicable "bugs." Hygienic routines
become especially important. As well, the practitioner should be alert to the
need to reschedule such clients' appointments when personally unwell.
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From assessment to treatment planning, massage therapists should
prepare for the variable effects medications can have on the services they
provide their clientele. |
Conclusion
The last two decades have witnessed several remarkable changes in the
perceptions and practice of health care in North America. Dramatic new
pharmaceutical agents have been developed, and they are being made available in
a marketing environment where prescription medications to treat everything from
high cholesterol to hypertension, anxiety and impotence are being promoted
directly to the public via television, magazine advertisements and the Internet.
At the same time, there has been an enormous groundswell of public interest in
and utilization of alternative health care by all sectors of the population.
Many have come to regard non-conventional or alternative therapies as
complementary to medical treatment, and are receiving such treatments while they
are also under the care of a medical doctor for various medical conditions.
Because of
this, massage therapists are more likely than ever before to regularly treat
clients who are also using prescription and non-prescription medications.
Unfortunately, many therapists lack formal training in the effects of
pharmaceuticals and how to adapt massage treatments in these situations.
Hopefully, by exposing practitioners to the potentially harmful interactions
between massage and some medications, massage therapists can feel better knowing
they provided the safest service possible to their clientele.
Notes
1 Eisenberg, D.M., et al., "Unconventional Medicine in the United
States, Prevalence, Cost and Patterns of Use," New England Journal of
Medicine, January 28, 1993.
2 Unconventional medicine was defined as "...medical interventions not
taught widely at U.S. medical schools or generally available at U.S. hospitals.
Examples include acupuncture, chiropractic, and massage therapy." "The
absorption of carbarnazepine in man is relatively slow. When taken in a single
oral dose the carbarnazepine tablets and chewable tablets yield peak plasma
concentrations of unchanged carbamazepine within 4-24 hours. Only 2-3% of the
dose, whether given singly or repeatedly, is excreted in the urine in unchanged
form. The primary metabolite is the pharmacologically active 10, 11-epoxide.
After repeated doses the elimination half-life of unchanged carbarnazepine is
16-24 hours depending on the duration of the medication.
3 Compendium of Pharmaceutical Specialties, 28th ed., Canadian Pharmaceutical
Association, Ottawa, 1993, pp. 1200-1201.
This
article is reprinted with permission from Randal Persad's Massage &
Medications, Curties-Overzet Publications, 2001.
Randal
Persad graduated as a pharmacist from the University of the West Indies,
Trinidad and Tobago campus, in 1986. He worked as a pharmacist and as a medical
representative for a leading pharmaceutical company. When he moved to Canada a
few years later, Persad encountered jurisdictional controls in pharmacy and
decided instead to pursue his life-long interest in massage. He returned to
school and completed the two-year program at the Sutherland-Chan School &
Teaching Clinic in Toronto. Currently, Persad maintains a private practice and
teaches Orthopaedic Assessment & Treatment, Hydrotherapy, and Massage
Therapy and Medications at a massage school in Vancouver. Persad's book,
Massage Therapy and Medications, can be purchased through Curties-Overzet
Publications, 888/649-5411.
Copyright © 1999 Active Health. All rights reserved.
Revised: January 29, 2008
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