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Should You Drink Water After Massage?

Only if you’re thirsty! Hydration and massage are not detoxification treatments

4,000 words, updated 2012
by Paul Ingraham, Vancouver, Canada bio
I am a science writer, the Assistant Editor of ScienceBasedMedicine.org, and a former Registered Massage Therapist with a decade of experience treating tough pain cases. I’ve written hundreds of articles and several books, and I’m known for sassy, skeptical, referenced analysis and a huge bibliography. I am a runner and ultimate player, and live in beautiful downtown Vancouver, Canada. • full bioabout SaveYourself.ca

Many massage therapists believe1 that “toxins” are “flushed” by massage and drinking extra water after you get off the table. Alas, which toxins and how exactly they are “flushed” by massage or water is all rather vague — and not a good reason for recommending water. Many therapists know it’s vague but apply the precautionary principle: drinking water certainly won’t hurt, right? No, probably not (although over-hydration is more of a problem than most people realize2). It’s polite and pleasant to offer post-massage water, but there’s no particular biological, detoxifying need for it. It’s about on par with a recommendation to “think positively” or “go for a short walk to get your blood moving” — fine things, but tepid medical advice.

Here’s a quick, rational tour of the topic by video from Laura Allen, a massage therapist in Rutherfordton, North Carolina. I get a big kick out of her folksy 3-minute debunking of this classic massage myth. Her no-nonsense Southern twang and well-chosen words are perfect for this job!

Laura Allen, Massage Therapist, on Toxins & Massage 3:14

How many massage therapists are still out there telling their clients that massage gets rid of toxins in the body? On any given day on Facebook, I see about half dozen people at least making that claim … Would you maaahnd sharing with us exactly how that happens?

Laura Allen, Massage Therapist

Which toxins are these, exactly?

There are real “toxins” and some legitimate “detoxification” treatments. But casual and careless use of these terms is almost always a red flag,3 and accompanied by a more or less perfect ignorance of which toxins. Are we talking about lead poisoning here? Pesticides? What chemicals? Dihydrogen monoxide?4 Magnesium sulfate?5 What?

The toxin-talkers do not know.

Or, worse, they think they know — but give examples that are mythical,6 and/or absurdly extreme.7

The body deals with undesirable molecules in many ways. It eliminates some and recycles others; some are trapped in a safe place; and quite a few can’t be safely handled at all (metals). Most alleged “detox” treatments are focussed on stimulating an excretion pathway, like sweating in a sauna. But it’s not like sweating is broken and the sauna is fixing it! The only truly “detoxifying” treatments help the body eliminate or disarm molecules the body cannot process on its own. A stomach pump for someone with alcohol poisoning is literally “detoxifying.” So are antivenoms and chelation for heavy metals.8

When massage therapists talk (or think) about detoxifying, they need to be much more specific: what molecule, how it normally works, and how massage or water intake supposedly improves the speed or effectiveness of normal biological waste processing (recycling, sequestering, or elimination).

Metabolically speaking

When pressed to be specific, most therapists will say “metabolic wastes” — chemical products of cellular activity — and never specify any exogenous toxin or poison that is remotely realistic as a target for “flushing” with massage or water.

Metabolic wastes are much closer to the truth. The rest of the article will stick to the idea that the only “toxins” relevant to massage are waste metabolites.

It’s also a really broad category, and it does not actually explain much, or narrow things down. Cellular chemistry produces a lot of molecules. And it’s not really nice to call them wastes — it’s a bit of a slur, a chemical prejudice based in ignorance. In fact, many of them are not really “wastes” at all…

Beautiful chemical you

As in the rest of nature, not much in cellular chemistry is wasted. Chemicals are re-used and re-cycled. There are many (many, many, many) of them, and they all go through complex pathways, many never even see the bloodstream (they hang out only in cells and between cells), and many are probably completely unaffected by any fluid balance issue (short of dying of thirst, which affects pretty much everything).

Indeed, most metabolic “wastes” actually have utility throughout a cascade of functional interactions. You literally don’t want to “get rid of” them. You want them to go through their normal chemical lifecycle, processed and re-processed. Trying to flush them out would be sort of like trying to improve a car engine by getting rid of the exhaust before it hits the turbocharger.9 Metabolic by-products are not just nasty chemicals pooped out by cells that just hang around, stuck in tissue, waiting for your friendly neighbourhood massage therapist to come along and flush them away.

There certainly is a class of molecules loosely described as “metabolic wastes,” but it’s unfair to paint them all with the same brush, assuming that they are harmful or toxic. In many cases, it would actually be harmful to flush them, if you could — because they are a critical part of beautiful chemical you!

Flushing: how could massage “release” toxins, anyway?

It’s clear that we still don’t have a fix on which toxins therapists are talking about. Let’s work with an example of a rock-star-popular waste metabolite: lactic acid, or lactate.

Lactic acid is the poster boy for the waste metabolites, probably the only one that’s a household name, and most massage therapists still assume that lactic acid can be squished out of muscle tissue and into the bloodstream. This is not a difficult thing to test, and it has been tested, and some results were a bit shocking: not only does massage definitely not “reduce” lactic acid,10 perhaps massage even “impairs lactic acid and hydrogen ion removal from muscle.”11

Whoops.

This is not really surprising. If people needed massage to help them “clear” lactic acid, sprinters would drop like flies without emergency massage after every race. The effect must be minor or non-existent.

In any case, it’s worth emphasizing that lactic acid is not the cause of muscle pain at any time except the immediate aftermath of intense exercise, and probably not even then. Lactic acid is actually a useful molecule with a productive metabolic fate, not a dead-end waste product.Recent (2008-2010) research has shown that muscle fatigue and the “burn” that you feel as you exercise intensely is probably caused by calcium physiology, not an accumulation of lactic acid.12 In particular, lactic acid does not cause soreness the day after exercise — it’s long gone by then.

And there’s more: lactic acid is actually a useful molecule with a productive metabolic fate, not a dead-end waste product. Lactate as a “bad” molecule is one of the most persistent silly myths in all of exercise science.13

So presenting lactic acid as some kind of metabolic bogeyman that massage can get rid of is wrong, wrong, wrong on many levels. And any other metabolic waste is even less likely to fit the bill. So this is another nail in the coffin of the silly notion that massage somehow “detoxifies.”

Now it’s time for a plot twist.

Oh, irony: poisoned by massage!

Massage is toxic?

Technically. But so is good scotch. And hard exercise.

Not only is massage not a detoxification treatment in any sense, it is actually the opposite: a toxifying treatment. A little bit. Sometimes.

Post-massage soreness and malaise (PMSM) is a common phenomenon after any strong massage. It is probably caused by mild rhabdomyolysis (“rhabdo”), a form of poisoning. True rhabdo is a medical emergency in which the kidneys are poisoned by myoglobin from muscle crush injuries.

However, many physical and metabolic stresses cause milder rhabdo-like states — even just intense exercise, and probably massage as well. This is substantiated by a case study of acute rhabdomyolysis caused by intense massage,14 by many well-documented cases of exertional or “white collar” rhabdo, and by the strong similarity between PMSM and ordinary exercise soreness (delayed-onset muscle soreness).

A rhabdo cocktail of waste metabolites and by-products of tissue damage is probably why we feel a bit cruddy after biological stresses and traumas — even massage, sometimes. It’s not that big a deal. Massage is still worthwhile. But it is, technically, a little bit toxifying — not detoxifying.

Nor can massage get rid of any rhabdo it causes. You can’t “flush” the rhabdo cocktail away with massage, or drinking a little extra water — or any amount of water. PMSM is just an unavoidable mild side effect of strong massage, just like soreness after intense exercise. I have a detailed article just about rhabdo, which explains exactly why it can’t be “flushed.” The rest of this article explains the futility of flushing in more general terms.

And how is water supposed to help anyway?

Even if there are problematic waste metabolites in your tissues, and even if they can be mostly liberated into the bloodstream … why would drinking a couple extra glasses of water help get rid of them?

There’s a prevalent and vague belief that drinking water somehow “rinses” your blood vessels or cells … or something. But your circulatory system is not a simple system of tubes that you can flush out by imbibing extra water. This makes about as much sense as adding fuel to a car to make it go faster.

In fact, fluid balance is quite stable and somewhat independent of modest changes in water intake. Drink some extra, drink some less — your blood volume will stay almost exactly the same. Your body is an “ugly bag of mostly water,” but the total amount of water in circulation — in your blood and between your cells — remains nice and steady. You only need so much of the stuff. Just like your respiratory system excels at maintaining constant levels of oxygen and blood acidity, your guts cleverly keep your insides just the right amount of wet. Drinking more water than you need doesn’t add it to your bloodstream — you just piss away the extra!

The liver and the kidneys are the primary detoxifying organs: this is where most junky molecules are transformed, disarmed, and/or excreted. And they don’t require extra water to work any more than they need extra food to work. Their elaborate chemistry marches on unperturbed, whether you drink 4 glasses of water per day or 12. If you are significantly dehydrated, of course you would certainly start to have problems — but liver and kidney failure are not among the early consequences!

The many fates of metabolites

Carbon dioxide is a prevalent waste metabolite, and an easy one to understand: your cells produce it via combustion of fuels with oxygen, like a trillion15 teensy car engines. It is found at high levels in myofascial trigger points (muscle knots), which are metabolically “revving.”16 To hammer home that this stuff really is a “toxin,” CO2 is also chemically equivalent to acidity: to be CO2-polluted is to be acidic!

But CO2 disposal just has nothing to do with water, nothing at all. Its fate is completely separate from fluid balance.

Carbon dioxide is processed at extreme speeds — quite “aggressively,” because we cannot tolerate much variation in acidity — primarily by a chemical pathway through the bloodstream and lungs: a pathway that does not much involve the kidneys, fluid balance, or fluid excretion. And the amount of CO2 involved in trigger point toxicity is a drop in an ocean of chemistry anyway. Even if massage squished a trigger point’s full cargo of CO2 into the bloodstream, that’s an infinitesimally small amount of CO2 compared to the total CO2 produced in a single second by all of the body’s cells. We produce and process vast quantities of CO2 constantly, and we do it effortlessly.

So much for that prominent toxin being flushed away by water!

And so it is with all the other “toxins” in a trigger point — problematic when concentrated in a patch, they are otherwise trivial and unaffected by water intake in any case. Even supposing that squishing a trigger point magically forces every molecule of every pain-causing metabolite into the bloodstream (not just into adjacent intercellular fluids, which is actually more likely), they still wouldn’t require further “flushing” by any means. Once in the bloodstream, they would be lost like motes in a sandstorm, joining billions of their metabolic siblings that are routinely produced — and processed — by all the cells of the body, and drinking water has no relevance to those processes.

What about “lymphatic drainage”? Isn’t that a clear example of detoxifying massage?

No. This comes up in most Facebook debates between massage therapists on this topic. It’s a red herring. Manual lymphatic drainage (MLD) is a fairly exotic and specialized manual technique for reducing swelling. Although it is performed with the hands and a natural fit for massage therapists to learn, it is not “massage” per se, and the effect is mostly absent from all other kinds of massage. I don’t know the evidence base for it and haven’t looked into it since I acquired the research skills to do so, but it’s effects are reputed to be substantial.17

In principle, MLD simply stimulates/exaggerates the normal action of the lymphatic system, the primary function of which is not waste disposal but the removal of excess tissue fluids, and then the filtration of lymph through nodules of immune cells (lymph nodes). Lymph nodes are really not at all like the liver, which actually is a “waste processing plant.” The liver is the organ that processes junk in your blood. Lymph nodes are about catching invaders, foreign microbes, which makes them more like “security check points.” You can see from this difference that it’s not really correct to say that lymphatic drainage is about “waste removal,” even if there are some cellular waste products in lymph (and there probably are).

Elephantiasis

This is what happens when lymph doesn’t flow — swelling, and lots of it. Not “toxicity.” It is easy to find many gruesome pictures of elphantiasis on the internet.

If lymph were critical for waste removal, then the major impact of failure of lymphatic drainage would be tissue pollution. But failures of lymphatic drainage — for instance, drainage can fail because of surgical damage to lymph vessels and nodes, and indeed that is why MLD exists as a therapy — do not result in tissue “toxicity” at all, but severe swelling (elephantiasis, in the most extreme cases). It’s super unpleasant, but it’s not an issue of toxicity.

So MLD isn’t really “massage” as we normally know it, and doesn’t “release toxins/wastes” in any case: that’s a gross misrepresentation of the physiology as I understand it, and cannot be used as an example of detoxifying massage.

A classic case of oversimplification

The idea that drinking water after massage matters is a hopeless oversimplification, easily undermined by a cursory understanding of biochemistry. Metabolic wastes are already ubiquitous in tissue fluids, and they are constantly being produced and recycled. While massage has never been shown to have any significant effect on these processes — except to actually impair lactic acid removal! — it doesn’t even make logical sense that water would have anything to do with it. Anything the body can get rid of it is going to get rid of, with or without massage, and with or without any extra water.

The body is good at handling metabolic wastes, and even many exogenous poisons, without any special help. If it wasn’t, we’d really be up the creek.

It’s certainly nice to offer patients some water after massage, to quench whatever thirst they may have. But it is not medically important for any specific biological reason, and it perpetuates several minor myths we would be better off without. Massage doesn’t really “detoxify.” Water doesn’t detoxify. And lactic acid is a useful metabolite, not a waste product. Adequate hydration is easy and mild dehydration is not a health risk.

About Paul Ingraham

I am a science writer, former massage therapist, and assistant editor of Science-Based Medicine. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook and Google, but mostly Twitter.

Further Reading

Appendix: What do massage therapists really believe about detoxification?

A common criticism of this article is that few massage therapists actually believe or say anything about detoxification at all — that it’s a myth that massage therapists believe that massage detoxifies. A myth myth? It’s a reasonable counter-skepticism, but it’s just speculation, and quite contrary to my extensive experience.

I have an unusually good sense of what “many massage therapists believe” because they tell me, constantly, for many years now, responding to my very widely read website. My email box is more or less constantly filled with examples. Here’s one that just happens to be in my inbox as I write this, from a discontented massage therapist writing about her clinic:

My boss has an infra red sauna and she wants us all (her staff) to try to get our clients to have regular saunas because they are good for ‘detoxing the body’. She always uses the mercury example of how we must rid our bodies of this insidious substance, citing that most of us have amalgam fillings in our teeth.

I have also witnessed many a Facebook argument on this topic — often triggered by this article — and there is often a militant “detox contingent” that clearly believes. For example, here is the first comment on a Facebook share of this article:

massage stimulates circulation, mechanically and metabolically, which is an enormous factor in "toxin" processing.

If not a militant “detox contingent,” even more inevitable is the innocent question (thoroughly answered above):

Doesn’t it help to flush lactic acid?

Sometimes I have heard massage therapists argue that it’s only a minority of bad apples and poorly-trained therapists who make detox claims. However, I was trained in British Columbia when 3000-hour training was standard18 — the longest massage therapy trianing program in the world. That’s where I first encountered widespread detox claims and beliefs! So it’s clearly not a belief that is limited to poorly trained therapists.

Another clue that detoxification claims are not so rare or mild is that it tends to come up, with depressing frequency as an excuse for adverse effects. Unpleasant symptoms in the aftermath of massage, even serious ones, are often attributed to a “healing crisis” brought on by the detoxifying effects of massage. I have heard such anecdotes (complaints) countless times over the years from massage therapy consumers; my own clients told me about them many times, and many more readers. For a particularly chilling example, see What Happened To My Barber?

Notes

  1. Do they really? I substantiate this in an appendix to the article, What do massage therapists really believe about detoxification? BACK TO TEXT
  2. Technically, it can hurt … and even kill. Excessive concern about dehydration leads to excessive hydration. And there is such a thing as “water toxicity,” and there have even been some deaths from drinking too much water, prescribed by alternative health care professionals who believe that chronic dehydration is the cause of many ills. That is not true. See Water Fever and the Fear of Chronic Dehydration. BACK TO TEXT
  3. The idea of “toxins” is usually used as a tactic to scare people into buying de-toxifying snake oil of one sort or another. It’s not that there’s no such thing as a toxin — obviously there are toxic substances in the environment. The problem is the kind of people who toss the idea around, the reasons they do it (profit), and the total lack of any specific claim or scientific knowledge or evidence to support it. It is so vague that it’s literally meaningless, except as a marketing message. Indeed, “detoxification” may be the single most common marketing buzzword in alternative health care. BACK TO TEXT
  4. You get a gold star if you spot the joke there. If you don’t get it, please return to grade 11 chemistry, do not pass go, and do not collect $200. But do read this explanation. BACK TO TEXT
  5. Another joke! Magnesium sulfate is Epsom salt — often touted as a detoxifying agent, but this is chemically illiterate and biologically absurd. The irony and the joke is that Epsom salt is actually mildly toxic if you eat it or inject it. But bathing in it? Epsom salt in your bath makes bath water feel “silkier,” but that’s about it. It isn’t biologically relevant to aches and pains, and chemically it may not even make it through the skin (osmosis is not even relevant). See Do Epsom Salts Work? There is no good reason to believe that Epsom salt baths aid recovery from muscle pain, soreness or injury. BACK TO TEXT
  6. Mercury from fillings is a classic example. Mercury is certainly dangerous, but dental amalgam fear-mongering is a scam that has been denbunked ad infinitum. See The "Mercury Toxicity" Scam: How Anti-Amalgamists Swindle People. BACK TO TEXT
  7. Environmental lead poisoning is real and can be crippling and deadly, but it is only treatable by chelation, and only partially. BACK TO TEXT
  8. Chelation is one of the few legitimate medical procedures that really does detoxify. However, it is also fairly limited and specific. Chelation is often used as a quack therapy for alleged toxins that it cannot actually treat. See Why Chelation Therapy Should Be Avoided. BACK TO TEXT
  9. A turbocharger reclaims some of the engine’s energy by using the exhaust to power a fan that forces more oxygen into the engine — positive feedback. It uses “waste” to make the engine work better. It’s a simple principle. If it can be found in car engines, you can rest assured that you’ll find it in cellular chemistry as well. BACK TO TEXT
  10. Crane et al. Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Science Translational Medicine. 2012. PubMed #22301554. This instantly famous gene profiling study was mostly reported because it supposedly proved that massage “reduces inflammation” (it doesn’t, and I explain that thoroughly in another article). Although the study was not about lactic acid, they did check that … and found that “there were no effects on muscle lactate levels” with massage. BACK TO TEXT
  11. Wiltshire et al. Massage Impairs Post Exercise Muscle Blood Flow and "Lactic Acid" Removal. Medicine & Science in Sports & Exercise. 2009. PubMed #19997015.

    One of the classic claims of massage therapy is that it “aids muscle recovery from exercise … by increasing muscle blood flow to improve ‘lactic acid’ removal.” Unfortunately, new evidence shows that just the opposite is probably the case. This straightforward experiment subjected twelve people to intense hand-gripping exercises and then measured their blood acidity with and without basic sports massage. Their measurements showed that massage significantly “impairs lactic acid and hydrogen ion removal from muscle following strenuous exercise by mechanically impeding blood flow.”

    That’s quite a surprising result that applies a firm push to the side of a classic sacred cow of massage lore. (Note that good corroborating evidence was published again in 2012: see Crane et al.)

    BACK TO TEXT
  12. See Bellinger, Fredsted, Wiltshire. BACK TO TEXT
  13. Lactic Acid Is Not Muscles' Foe, It's Fuel. Kolata. www.nytimes.com. 2006. BACK TO TEXT
  14. Lai et al. Fever with acute renal failure due to body massage-induced rhabdomyolysis. Journal of Nephrology, Dialysis and Transplantation. 2006. PubMed #16204282.

    Interesting, short, and readable story of an elderly man who collapsed after an unusually strong massage.

    BACK TO TEXT
  15. Or more. See Ten Trillion Cells Walked Into a Bar. BACK TO TEXT
  16. Shah et al. Biochemicals associated with pain and inflammation are elevated in sites near to and remote from active myofascial trigger points. Archives of Physical Medicine & Rehabilitation. 2008. PubMed #18164325.

    This important paper demonstrates that the biochemical milieu of trigger points is acidic and contains a lot of pain-causing metabolites: good evidence in support of the energy crisis theory of trigger point formation and/or perpetuation. It’s an improvement on an earlier paper from 2005 (Shah), with improved methods. It is cogently summarized by Simons, and in my short article Toxic Muscle Knots.

    BACK TO TEXT
  17. In my terms, it apparently passes “the impress me test” in a way that no other massage technique does. That is, it’s a technique with effects so impressive that there is little room for controversy or argument. Assuming that it actually does significantly reduce edema. I have never actually witnessed it. Eventually I’ll update this with firmer evidence. BACK TO TEXT
  18. SY Ingraham. Massage Therapy In British Columbia (Canada): Training, credentials, and the state of the profession of massage therapy in this province. SaveYourself.ca. 980 words. BACK TO TEXT