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40 m a s s a g e & b o d y w o r k j a n u a r y / f e b r u a r y 2 0 1 8 education PATHOLOGY PERSPECTIVES 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 SA MS. 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 SA MS. Someone said, "Ask Ruth," which they did. I was stumped. I had no idea whether it was safe and appropriate for a person with SA MS 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 Statin Use and Massage Therapy Common Side Effects of a Common Drug By Ruth Werner 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