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published 11/26/07, updated 3/22/10

A Review of ART® Therapy

Concepts and controversies in Dr. Leahy’s “Active Release Techniques®” (ART) method of massage therapy for chiropractors

by Paul Ingraham, Vancouver, Canada MORE
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Credentials and qualifications

I am a writer and retired Registered Massage Therapist (unusually well-trained for a massage therapist, a 3000-hour program). I’m almost done with a Bachelor of Health Sciences degree. I am a peer reviewer for The Natural Standard, and a copyeditor for Science-Based Medicine. My most important qualification is more than a decade of workaholic post-graduate study, clinical experience, and constant conversations with readers from around the world, including many experts who have provided countless suggestions and criticisms.

For more information, see: Who Am I to Say? More information about my qualifications, credentials and professional experiences for my readers and customers.


Active Release Techniques® (www.activerelease.com)1 is a popular kind of “deep tissue” massage with a strong focus on a massage concept known as “pin-and-stretch” — applying pressure to a muscle as you elongate it. ART is a commercial success: it's widely available around North America, mainly in chiropractic offices. Patients and readers often ask me about ART, and report mixed results. Some people certainly believe it has helped them. Many others do not. Where does ART fit into the world of physical therapy?

Always remember: talented individual therapists always have the potential to transcend the limitations of a particular kind of treatment. That’s why you should Choose the Therapist, Not the Therapy!

ART advertising and image

The official ART website claims that it is “a patented, state of the art soft tissue system/movement based massage technique.” The mention of a “state-of-the-art” patent makes it sound special. Patenting a therapy does not mean that it’s an effective therapy, of course — it simply protects the patent holder’s right to financially exploit a distinct concept without competition.2

ART is often portrayed as a kind of “sports massage”, but there is no particular reason why ART should be considered more appropriate for athletes than for anyone else, or more than many other popular manual therapies. However, note that such a portrayal is a basic marketing tactic to associate a product with young, healthy people.

ART is not innovative or distinctive from the point of view of a well-trained massage therapist. ART may be patented as a certification product, but pinning-and-stretching is not patented or exclusive any more than (for example) basic Swedish massage techniques are. Many massage therapists employ pin-and-stretch and other ART-like techniques, but aren’t limited to them, either.

ART is “massage for chiropractors”

ART is strongly associated with chiropractors. It was created by a chiropractor, and most providers of ART are chiropractors.

The creator of ART is Dr. P. Michael Leahy, DCC. Dr. Leahy is also credentialled as a Certified Chiropractic Sports Physician (which is not a medical credential despite the word “physician.”3).

So you can pretty much think of ART as “massage for chiropractors.” It is what chiropractors offer when they want to include some massage therapy skills in their practice. This is commendable in itself — they should probably be encouraged, because massage is good — but also suggests something about its limitations.

The reasons Dr. Leahy gives for ART

Pin-and-stretch massage has never been specifically studied. It is completely unknown whether or not it is more or less effective than any other kind of massage therapy, and the effectiveness of massage therapy itself is generally unknown (more below). So there is no proof or any evidence at all that ART works, and only the “idea” of it can be considered. The rationale for ART is presented like this on the website, with no elaboration or supporting research. This is the sole published source of official information about why ART is proposed to be good for you.

How do overuse conditions occur? Over-used muscles (and other soft tissues) change in three important ways:

I disagree that these are the “three important ways” that over-used muscles and other soft tissues change.

Acute injuries like pulls, tears and “collisions” are, by definition, not overuse conditions, nor the obvious consequence of overuse injuries, and I can only speculate what this point is intended to communicate. Acute injuries are generally untreatable in the acute phase of healing: it is mostly ineffective and/or risky to attempt any form of direct, strong massage therapy on an “acute” injury.

Microtrauma may be a factor in muscle pain, but the word is a red flag, because it often gets used without specific knowledge, like references to unspecified “toxins” or “quantum.” Physiologists simply do not know whether or not “microtrauma” has anything to do with chronic pain and injuries that don’t heal. Nor is it known what kind of physical therapy might help microtrauma, even if it is present and clinically meaningful.4

Oxygen deprivation is not generally a result of “over-used muscles (and other soft tissues)" to the best of my knowledge. Professional readers are invited to present me with scientific evidence correlating “over-used” muscles with hypoxia. The only possibility I’m aware of is the phenomenon of myofascial trigger points (see below). Perhaps more to the point, no kind of massage has ever been shown to do anything about hypoxia directly or significantly. Even if hypoxia has some role to play in overuse conditions, it’s questionable whether any kind of massage is an effective treatment for it, and there is no reason to believe that ART would be any more or less effective than dozens of other potential therapies.

What about trigger points?

Trigger points — muscle knots — are hardly the only good reason to massage people, but they are probably the best and most specific reason to massage anyone,5 and there is now fairly compelling scientific evidence of this.6 Treating trigger points gives the best bang for the massage buck for most patients with chronic muscle pain. And trigger points are certainly relevant to the most prominent target market for ART providers (that is, athletes).

Trigger points — muscle knots — are pretty much hands down the best reason to massage anyone.

Unfortunately, ignorance about trigger points is a great weakness in primary health care in general, and even in the various manual therapies. Surprisingly few manual therapists are qualified to treat trigger points, as has been asserted by every key author on the subject. In general, this is due to wrong training, incomplete training, and medical distraction with many clinical problems that are more serious than muscle pain. (As real a problem as muscle pain is, it tends to be overshadowed by trauma, infection and disease.)

Trigger points are the most obvious and damning omission from ART’s marketing language — the most obvious credible reason that ART might be effective. Trigger points are well known to science, and clearly aggravated by over-exertion, so it is surprising indeed that Leahy doesn’t claim an effect on trigger points as a reason for ART’s effectiveness. Furthermore, in my experience, ART providers don’t generally know any more about trigger points than most undertrained massage therapists. Therefore, ART in its current state is one of the weakest options available for trigger point therapy.

A massage is a massage is a massage

I am not a chiropractor, and thus I would never claim to be skilled at an treatment such as spinal manipulative therapy. Similarly, I am skeptical that chiropractors practicing ART can claim to be as skilled at any kind of massage as a massage therapist. Practice makes perfect, and massage therapists simply get a lot more practice massage. This also raises the question of whether ART, as practiced in general, is a reliable source of good massage.

On the other hand, in some ways any kind of massage is like pizza: even when it’s not very good, it’s still pretty good. It’s also possible for a thorough, firm massage to more or less accidentally do some good! Hence the huge market for not-very-qualified massage therapists.

And a talented chiropractor who knows anything at all about trigger points will probably do ART in a way that is at least “trigger point friendly,” focussing on at least some relevant muscle knots. But ART may not be a good choice when there’s significant need for competent trigger point therapy (as there often is).


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What’s New In this Article?

Monday, March 22, 2010 — Corrected some typographic errors.

Notes

  1. ART is usually called by its initials, as in “ay ar tee.” Note that ART doesn’t stand for “active release therapy,” a common error. The registered trademark is for “techniques”. Return to text.
  2. Patent. Wikipedia.com. “A patent is a set of exclusive rights granted by a state to an inventor or his assignee for a fixed period of time in exchange for a disclosure of an invention.” Return to text.

  3. Many alternative health care professionals often claim that they are as well trained as physicians. This is not factual. Doctor’s academic training is routinely longer, and — more importantly — most of their serious learning occurs during extensive on-the-job training, where they are thrust into demanding clinical environments and supervised for years as they deal with a great variety and number of clinical situations. That hands-on phase of their training is where all doctors will tell you that they became professionals — and there is nothing like it in any non-medical health care training.

    Return to text.
  4. For instance, Researchers can’t even determine the significance of microtrauma in delayed-onset muscle soreness — the most obvious physiological situation in which it might actually be a factor. Return to text.
  5. Simons et al. Muscle Pain, pp205–288. A book within a book, Mense and Simons’ chapter on myofascial trigger points is a more recent version of the introductory chapters of the seminal Myofascial Pain and Dysfunction. It is probably the most complete and current source of information on the subject today, and therefore essential reading for any health care professional who deals with aches and pains. Unfortunately, I also believe the authors have oversimplified key points and neglected others in the attempt to stay consistent with a few interesting facts that have been more or less confirmed by research evidence. In other words, all they have is an evidence-based hammer, and so they are only writing about nails. But it is a pretty good hammer! Return to text.
  6. Furlan et al. Cochrane Database of Systematic Reviews. 2008. This review of 13 studies of massage therapy found that “massage is beneficial for patients with subacute and chronic non-specific low-back pain in terms of improving symptoms and function,” and that it “may save money” and the benefits “are long lasting (at least one year after end of sessions).” Although the studies were of poor average quality, most found clear evidence of benefit, and the better quality studies found even clearer evidence of benefit — precisely the kinds of results expected from a therapy that is difficult to standardize, but nevertheless effective. The data so far are still not conclusive, but they do strongly suggest that massage works for low back pain. Return to text.