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Does Massage Therapy Work?

A review of the science of massage therapy … such as it is

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.


Does massage therapy “work”? What do massage therapists say that they can do for people and their pain, and is there any scientific evidence to support those claims? In this article, I examine massage therapy in the light of science.

Summary of the Article

Support for the points made in this summary will be discussed below.

Many massage therapists offer patients some services of dubious medical value, even where training standards are high, and training standards in most places are low or nil. However, massage therapists get so much hands-on experience that they often learn to serve some patients well regardless of limited training. Their successes are probably mostly due to the effects of pressure on myofascial trigger points (“muscle knots”), a somewhat treatable factor in many common pain problems. For instance, the best scientific evidence available so far indicates that massage is probably an effective treatment for low back pain.

Massage probably also has many subtle and minor benefits, especially pleasure and relaxation. Massage therapy always has at least that much to offer to patients. But a well-trained “medical” massage therapist can also offer many other useful services, such as rehabilitation coaching and specific evidence-based manual therapies for a variety of injuries and pain problems.

These services can result in an effective combination, if a patient can find a therapist offering a good selection of them. Unfortunately, in most jurisdictions, massage therapists lack even the most basic training in orthopedics and rehabilitation.

I saw a few chirpractors and acupuncturists. But despite some initial short relief, their work seemed to lose effectiveness after a few visits. I went to a massage therapist, whose treatment actually was the opposite of my experiences with neurologists: It was enjoyable. This was the beginning of what I called a foray into “recreational medicine.”

All In My Head, by Paula Kamen, p115

Types of massage therapists

There are a few “medical” massage therapists out there with some training in orthopedics and rehabilitation. My education in massage therapy here in British Columbia, Canada, was three years long — the longest massage therapy training program in the world. There are also a few other places with two-year programs. This is certainly the kind of massage therapist that patients should seek out if they want massage as a treatment.

Many massage therapists have almost no training at all, and are not qualified to treat any kind of medical problem.

Unfortunately, such massage therapists are quite rare in the world. The vast majority are poorly trained and uncertified. Most work in spas, resorts and on cruise ships, doing treatments that are infamously fluffy and skin deep, with little therapeutic value other than the comfort of a quiet hour of touching (even though many patients find skin-deep massage to be more annoying than anything else). Most of these therapists are earnest and view themselves as paramedical professionals, despite their comparative lack of training. It’s actually inappropriate to call them “therapists” at all, and in some places (here) it’s actually illegal — they have to use terms like “bodyworker” or “masseuse.”

Interestingly, all the most pleasant massages I have ever had were done by therapists of this type! Compassionate and emotionally mature people are drawn to the work and usually think of it as a bit of a calling — perhaps this affects the sensory quality of the experience more than technical training.

The trouble with studying massage

Massage can be studied: we don’t have to know how something works to find out if it works. Do people who are sick or broken get better when massaged?1

But logistics and economics get in the way. Scientists are not much interested in studying massage, while massage therapists don’t have scientific training. It’s an expensive and overwhelming challenge for a massage therapist to make room in their career for some research — few do it, and hardly any have ever done it well.2

So the quality of scientific studies of massage therapy, like all kinds of alternative health care, is generally poor.3 There are many common problems: studies so small they are almost meaningless, lack of standardization of treatment, failure to compare treatment to a placebo, lack of duplication by other researchers, and on and on. Worst of all is that “massage” can mean so many things that it’s hard to know what is even really being studied.

Research in the massage therapy field is still in infancy partly due to a lack of research infrastructure and a research tradition. The result is that most registered massage therapists are not accustomed to reading, analyzing, conducting, writing case studies or applying research in their own practice.

Harriet Hall, RMT, PDP, from “Vision of Specialization for Registered Massage Therapists”4

The scientific case for massage therapy

Massage for low back pain is the most studied massage question, and the answer is fairly clear — it probably works. More below.

Unfortunately, most other evidence about massage benefits is indirect and/or weak. Some research helps us to understand why people like massage, or why it’s likely that there are numerous minor massage benefits. But there are no smoking guns, no “proof” of that it “works” — that is, clinically significant therapeutic effectiveness for a good variety of health problems.

Many things that work may not yet have evidence, but that’s no excuse for overselling them. The soul of scientific, ethical health care is that we don’t oversell a treatment until there’s evidence that it really works.

For instance, basic research has shown that touch is neurologically complex and probably has many physiological effects. In 2009, Swedish researchers identified specialized nerve fibers that respond only to light stroking of a certain speed.5 This is interesting, and certainly suggests that massage can provide a rich and novel sensory experience — surprise surprise! — but it is far from proof that massage can fix anything.

Another good example: massage therapists and their clients generally assume that massage is relaxing, and that assumption certainly appears to be correct6; the idea is further supported by evidence that massage therapy reduces blood pressure78 and helps people to sleep, even when they are under the unusual stresses of hospital care.9 These are all unsurprising … and unremarkable. Relaxation is an important component of wellness, but hardly curative. And, as many critics have pointed out, massage is a really expensive way to relax. A nap is also relaxing.

Many studies10 done by the Touch Research Institute — although undoubtedly a bit biased11 — show many other broadly defined modest benefits to massage therapy in a wide variety of circumstances, everything from arthritis12 to cancer13 to autism.14 In a recent study in Annals of Internal Medicine, both massage and ordinary, simple touching have been shown to help cancer patients — indicating that massage was helpful and yet unremarkable at the same time.15

When massage isn’t even massage

Massage therapists choose from literally hundreds of different ways of trying to help people with their hands, many of which are not actually “massage” as we usually think of it. The majority of these manual therapies are nearly untouched by science. Many are dubious and obscure, while others are quite familiar and mainstream. Some of them may well be effective, but for what? Often the usefulness of this mish-mash of techniques is specific and debatable.

As I write this, my wife is recovering from serious injuries she got in a car accident, including a spinal fracture. Guess what exercises she has to do? Early mobilization and range of motion exercises! This is just mainstream, standard post-injury care. If a massage therapist prescribes it, then massage therapy is “working” for that patient.

Early mobilization and range of motion exercises, for instance, will be taught by competent massage therapists to clients with cervical injuries, because they help people get better faster.1617 In fact, the evidence strongly suggests recovery from nearly any injury or surgery is greatly facilitated by early mobilization.18 But that’s not “massage” — it’s something that a few well-trained massage therapists prescribe, and only in specific circumstances.

Lymphatic drainage is a great example of a really specific massage technique used to reduce serious swelling. It is probably the best treatment option for patients suffering from lymphoedema, a serious complication of mastectomy and other surgical procedures.19 But it’s obscure, technical, and practiced by no more than a few hundred therapists globally. It works nicely, but it’s not “massage therapy” per se, just a specialized tool that a tiny minority of professionals are trained to do, some of whom happen to be massage therapists.

There are many other examples of plausible, evidence-based advice and treatments that better-trained massage therapists will know about. But there’s also the many manual therapy techniques that are surprisingly un-proven, including some extremely popular ones.

Traction is a great example — pulling on the spine. Often used by massage therapists to treat low-back pain and neck pain, it might be an effective technique for a few patients, but I wouldn’t count on it, or advise anyone to spend much money on it. Like many popular therapies, the evidence is basically just a mess.20 The absence of conclusive evidence is significant: if traction worked well, it probably would have shown up clearly by now. If traction works at all, it’s certainly not reliable.

Friction massage, another very specific form of massage intended primarily as a treatment for tendinitis, was pioneered by physiotherapists and adopted unquestioned by massage therapists. Unfortunately, although it’s a reasonable idea, it has yet to be satisfactorily supported by the evidence — indeed, it has been undermined by it so far.21 Yet the profession clings to it, essentially because “it must be good” if physiotherapists do it.

Massage therapists routinely use techniques that are even more questionable.

Therapeutic “touch” — which involves no actual touching, but hovering over the body and manipulating the patient’s “aura” — is a prominent example. It’s not massage, and I think it’s in the same category of credibility as astrology or dowsing.22 Some massage therapists “believe,” while many others believe it’s nonsense.23

Craniosacral therapy is another classic example — popular for decades, it is a touch therapy, not “massage,” and it has never enjoyed one minute of respect from doctors or scientists, and has always been criticized by many alternative health professionals.24 Yet the therapy is sold with great (over!) confidence by millions of massage therapists, osteopaths and chiropractors, as though it were proven medicine worth spending piles of cash on.

There are many other examples of such dubious treatments. See the further reading list at the bottom of this article.

“Massage therapy” is often not limited just to Swedish massage. The other things that massage therapists do are a real mixed bag of standard manual/physical therapies along with many, many other things.

Massage for back pain: almost evidence-based!

Save Yourself from Low Back Pain!

There are thousands of low back pain books — what’s special about this one? The problem is that 90% of doctors and therapists assume that back pain is structural, in spite of mountains of scientific evidence showing … exactly the opposite. Only a few medical experts understand this, and fewer still are writing for patients and therapists. Supported by 198 footnotes, this tutorial is the most credible and clarifying low back pain information you can find. Ships with a free copy of SaveYourself.ca’s trigger point tutorial! Add it to your shopping cart now ($19.95) or read the first few sections for free!

This topic is covered really thoroughly in SaveYourself.ca’s detailed low back pain tutorial. If you really want to understand massage for low back pain, that’s what you need to read.

Low back pain is a huge health problem, and massage therapists claim to get good results when treating low-back pain. Indeed, low back treatments are the bread and butter of the profession. I guess that about 75% of massage purchases are for back pain. The amount of money that patients around the world spend on massage for back pain must be simply huge, certainly at least in the tens of millions annually and probably much more. As with chiropractic care, massage therapists might not have much of a business model if people didn’t have low back pain.

So it had better work!

And, fortunately, the evidence seems to suggest that it does. Over 20 years, an accumulation of scientific evidence has been adding up to a nice conclusion: that massage therapy probably does work for low back pain. That’s the finding of a comprehensive review of the science, from a 2008 review by Furlan et al:25

Massage is beneficial for patients with subacute and chronic non-specific low-back pain in terms of improving symptoms and function … The beneficial effects of massage in patients with chronic LBP are long lasting (at least one year after end of sessions).

That glowing conclusion was based on just 13 trials (about 1600 participants), and the best of data of the lot is merely okay. But massage “wins” anyway. Massage mostly performed brilliantly in these tests. And, better yet, the results were also positive in the more rigourous tests.26

So, is massage therapy for low back pain “proven” to be effective? Ha! Not by a long shot. But the science is off to a good start — much better than most other popular low back pain therapies. It’s genuinely promising. Remember, once again, this evidence is examined in much greater detail in my low back pain e-book.

Many experts and skeptics seem to like massage (or at least tolerate it), and few are critical

In the summer of 2009, I attended the Science-Based Medicine conference and The Amazing Meeting 7 in Las Vegas: a huge gathering of skeptics, scientists and critical thinkers. I was the only alternative health care professional at the conference that I know of. I introduced myself publicly to a couple hundred doctors and scientists as a “skeptical massage therapist.” They were delighted, and for the next four days skeptics approached me regularly to say, “Hey, that was brave! But massage isn’t quackery, is it?”

It's a fair question. Despite the lack of direct evidence, massage generally seems to get a stamp of approval from medical experts. For instance, you can probably trust the opinion of back pain expert Dr. Richard Deyo: he is openly skeptical about most other back pain therapies, but acknowledges that “promising preliminary results of clinical trials suggest that research on massage should be assigned a high priority.”27

Patrick Wall, the eminent neurologist and pain researcher, writes only a single word about massage therapy in his seminal book about pain, but it is a rather positive one: “Delightful.”28

Sam Homola, DC, a chiropractic “heretic” and author of Inside Chiropractic: A Patient’s Guide, writes, “We … know that massage may be as effective as cervical manipulation in relieving tension headache.” (p147) Dr. Homola is extremely critical not only of chiropractic, but of many other alternative health care practices as well, and he clearly does not tolerate irrational claims of therapeutic efficacy. And yet he is content to make this positive statement about massage therapy. That constitutes a good endorsement!

Dr. Stephen Barrett is a prominent anti-quackery activist. In an article on his popular website, QuackWatch, Barrett condemns common non-massage practices in massage therapy, but not massage itself: “ordinary massage and the legitimate practice of massage therapy should not be categorized as quackery.”29 That’s surprising tolerance from such a fierce critic of questionable health care.

The approval of skeptics doesn’t mean that massage “works,” and they may actually be giving massage more credit than it deserves. At TAM7, I repeatedly explained to horrified skeptics — who were trying to give me the benefit of the doubt — that my colleagues routinely either sell or endorse virtually every imaginable form of alternative health care, including the silliest: ear candling, crystal therapy, iridology, gong therapy (look it up!) … you name it, there’s a goofy therapy that many massage therapists “believe” in.

But the general approval of smart, critical experts certainly does generally indicate that the value of massage itself is strongly plausible — and that simply isn’t true of many other common therapies in the marketplace. Consider how much anti-quackery activists object to chiropractic!

When massage goes badly

People think of massage therapy as a “safe” therapy, and of course it mostly is. But things can go wrong. Serious side effects in massage therapy are rare, however, and common side effects are minor. A 2007 survey of 100 massage patients30 found that 10% of 100 patients receiving massage therapy reported “some minor discomfort” in the day following treatment. This would mainly be a familiar slight soreness that is common after a massage — I’m surprised only 10% reported it. The massage must have been quite gentle.

Interestingly, 23% reported unexpected benefits that had nothing to do with aches or pains.

(Also interesting is that this means that most of these patients experienced no noteworthy effect at all, good or bad! Hopefully they enjoyed the massage at the time …)

Another article covers this subject in more detail:

SY What’s the Harm? — Adverse effects of massage therapy

The scientific case against massage therapy

In addition to the many questionable non-massage therapies that massage therapists may offer, there are also many claims that massage therapists make about massage that are questionable. Most are not terribly important — just carelessly perpetuated minor myths — but they add up to a pattern of intellectual laziness in the profession that undermines its credibility and legitimacy.

Increased circulation. Massage therapists are particularly fond of claiming that massage “increases circulation,” but it doesn’t really.313233 It’s just kind of a silly claim — it doesn’t even matter if massage increases circulation a little, because so does exercise.

Detoxification. Another embarrassing chestnut is the detoxification claim — no one who says it ever has the slightest clue what they really mean. “Detoxification” sounds good, means nothing, and is repeated by countless massage therapists as one of the key reasons for rubbing. There is no scientific evidence about it one way or the other because it is too vague and silly to even be studied. There are such things as toxins in the world, of course, but mostly they are serious poisons, such as mercury in tuna, or lead in paint. Do you imagine for one moment that massage “detoxifies” these substances? Not a chance!

Lactic acid removal. If you challenge massage therapists to name a “toxin” that they are “removing” or “flushing” from your body, some of them will be quick to name lactic acid. This is based on ignorance of the phsyiology of lactic acid, which accumulates rapidly in intense exercise, but is also rapidly eliminated (in a matter of seconds or minutes). Evidence has actually shown that massage interferes with lactic acid elimination. See the lactic acid section below.

Delayed onset (post-exercise) muscle soreness. Supposedly, massage therapy can prevent or minimize that awful soreness that develops after an unfamiliar athletic effort, known as delayed onset muscle soreness. This is also almost certainly false, or at least greatly exaggerated — DOMS is mostly untreatable.34 And, as with circulation, it wouldn’t matter much even if it were true. Although DOMS can be pretty unpleasant, it’s one of the most trivial of all pain problems, guaranteed to solve itself within three days.

Endorphins. The word “endorphin” reached buzz word status a few years back, and is now often invoked carelessly. Endorphins are a class of neuropeptides that act on the nervous system to reduce pain and increase euphoria. But, although massage therapy may certainly reduce pain by a variety of mechanisms, it probably doesn’t do it by putting more endorphins into the blood stream.35 And, yet again, it wouldn’t be that big a deal even if it were true. Like relaxation, endorphins are good, but can only do so much.

More about lactic acid and detoxification

It’s worth devoting a bit more attention to this particularly classic controversy in massage therapy: that massage can aid muscle health and recovery from exercise by flushing metabolic wastes from your muscles (and therefore, logically, other “toxins” and metabolic wastes), especially the most famous one: lactic acid. This is not a difficult thing to test — the principle is science-fair simple, just compare metabolic waste products with and without massage involved — and it was recently tested, by researchers at Queen’s University in Kingston, Ontario.36

Wiltshire et al subjected 12 people to intense hand-gripping exercises to boost blood levels of lactic acid and other waste products of muscle physiology. Then they measured those substances with and without the subjects receiving basic sports massage. Their data showed that massage significantly “impairs lactic acid and hydrogen ion removal from muscle following strenuous exercise by mechanically impeding blood flow.”

Massage actually slowed down recovery from exercise, as measured by lactic acid levels.

That’s quite a surprising result that applies a firm push to the side of this classic sacred cow of massage lore. It’s only evidence, not proof — but look at that data! Read the abstract! It ain’t subtle.37

In any case, lactic acid is not the cause of muscle pain at any time except the immediate aftermath of intense exercise, and probably not even then. 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.38 In particular, lactic acid does not cause soreness the day after exercise — it’s long gone by then.

So presenting lactic acid as some kind of metabolic bogeyman that massage can get rid of is probably wrong on many levels. This is another nail in the coffin of the daft notion that massage “detoxifies,” and yet another reason to be suspicious of any therapist who talks about “detoxification” (as is often done to rationalize adverse effects of therapy that actually have other causes39).

What stinging rebuttal do sports massage therapists have to all this, particularly the Queen’s study? Here’s a highlight from their direct reply:

Notably, CSMTA Sport Massage Therapists are trained not to use deep tissue massage in an immediate post event environment. Years of sport massage practice have demonstrated that it does not improve recovery and generally leads to soreness. In fact, this study confirms this position as results showed exactly that response.

Response to Queen’s Study, Paula Burchat, Canadian Sport Massage Therapists Association (CSMTA.ca)

Well, so much for controversy! Massage has many interesting physiological effects, but getting rid of acid in your blood is certainly not one of them.

Limitations of massage (even at its best)

The evidence shows that massage is an effective treatment for low back pain, and yet the world has not been saved from back pain. What’s wrong? Why isn’t massage immediately, completely and permanently fixing every back pain client?

Because there are many kinds of both massage and back pain. Results of therapy vary widely with the skills of therapists, and with the specific kinds of back pain brought to them. And so, on average:

It’s not surprising, then, that some scientific studies show that low-back pain is not helped by massage therapy.404142 What’s actually surprising is that massage even works as well as it does.

A theory: why massage works, but usually not all that well

Massage’s primary therapeutic effect is not relaxation, toxin removal or increased circulation. It’s probably the relief from muscle “knots” — myofascial trigger points.

Trigger points are generally common and particularly tend to crop up as painful complications of many other kinds of painful problems. Thus many such problems can be at least partially helped simply by rubbing muscles in the area, creating some illusion that all problems are muscular problems. Back pain is the classic example.43

If this is correct, it would explain the perpetual appeal of massage — it can usually take the edge off — but also its inability to work miracles. If trigger points are the main reason massage seems at least a little bit helpful in so many cases, they are also the reason that the results are so upredictable. The best ways to treat trigger points are simply unknown — all trigger point therapy is educated guesswork. Therapists have greatly variable education, skill and luck in this process. Most simply aren’t that good at it — they can’t be, because muscle pain physiology is obscure, complex and basically way out of their league.44

For instance, therapists are unable to reliably diagnose trigger points45 — and it is hard to attempt to treat what you cannot even find. And when you have found them, the best evidence-based approach to treating them is simply unknown. There are dozens of distinct approaches to treating trigger points, and not one of them is much more than an educated guess. And every patient seems to respond differently (for instance, some patients have clear cravings for brutal intensities of treatment that would literally cripple another patient).

On the other hand, hands-on experience is valuable too, and anyone who’s had a good massage is familiar with the seemingly magical way that a therapist can find the perfect spots and “good pain.”

But countless known and unknown factors influence the outcome — far too many. The result is therapeutic unpredictability and mediocrity.

Economic pressure and the stereotype of hippy health care

Even in places with high training standards, massage therapists almost always have to sell themselves to clients who are paying hard-earned cash, so it’s not hard to see why massage therapists become habitually overzealous in promoting therapeutic services for which there is little evidence, no evidence, or only a mess of controversial evidence.

The road to intellectual dishonesty is paved with good intentions. When I worked as a therapist, there were times when I didn’t bother to explain to a patient that I was selling them a dubious approach to therapy. Sometimes it seemed okay because the atmosphere of experimental treatment was thick already, with a desperate patient who had low expectations and was pretty much there to “try anything.” But it was still dishonest, and I’m ashamed of those times. For the unwary, such dishonesty can become routine.

And many are unwary and have no idea that what they are doing is unethical. The stereotype of massage therapy as “hippy health care” is still strong, because a large number of massage therapists, probably the majority in North America, are what many people would describe as “flaky” or leaning in that direction. Such therapists are mostly ignorant of how science works, and actually hostile towards the idea of evidence-based care. They define themselves in opposition to the “mainstream” and distrust of The Man more than by their scientific and clinical knowledge and skills.

If scientifically unsupportable practices are surprisingly common amongst medical massage therapists, they are close to universal among barely-trained and untrained bodyworkers. Many of them aspire to greater skill, but usually don’t do so by studying orthopedics and physical therapy — a project that could occupy anyone for a lifetime — but instead by increasing their repertoire of certifications in proprietary hands-on techniques,46 most of which are either silly and/or medically unimportant (i.e. pleasant and harmless, but producing no significant therapeutic effect for any important health problem — hot stone massage would be a good example of this).

And that is why most people still go to a doctor or physiotherapist when they have an obvious injury.

So, does massage therapy “work”?

Hopefully it’s now obvious that this is not quite the right question. Does it work for what? What kind of massage therapy? How do we even define the benefits? Is modest, unreliable, temporary relief from muscle pain a significant enough benefit to base a profession on? Do a few subtleties like “relaxation” add up to “works”?

Good massage therapists are the ones with more training and a bigger toolkit. They do what they can with the tools they judge to be the most useful, and they candidly discuss risks, benefits, evidence and controversies.

The bad ones oversell a narrow selection of less effective faith-based options, and generally lack the training or critical thinking skills to recognize their own limitations. This is no different than any other health care profession.


What’s New In this Article?

Tuesday, April 6, 2010 — Some updates to the recently added section, More about lactic acid and detoxication, especially concerning evidence that lactic acid is not responsible for muscle pain and fatigue.

Saturday, March 27, 2010 — Added a nice quote from Hall.

Friday, March 26, 2010 — New section based on fascinating new scientific evidence, More about lactic acid and detoxication.

Tuesday, February 23, 2010 — Major revision, with focus on adding evidence about the effectiveness of massage therapy for back pain, updating numerous citations, and better explanations of how massage research works (or doesn’t).

Tuesday, September 16, 2008 — Added information about the new study in Annals of Internal Medicine about massage therapy for cancer patients.

Further Reading

Notes

  1. Tests of effectiveness are not difficult to cook up in principle: just take a hundred people with a certain kind of problem, give a well-defined kind of massage to fifty of them, a neutral treatment to the other fifty, record the results, and report them. Return to text.
  2. And even when they do, you’d be amazed how hard it is to even find 100 people with the same problem, and so studies of that size are almost never done: instead you get studies of 20 or 30 patients, which isn’t actually enough to prove anything. Return to text.
  3. One notable exception is the research produced by The National Center for Complementary and Alternative Medicine — by far the best-funded alternative health care research ever. Many NCCAM studies are of good quality. Unfortunately, their results have been infamously negative, and the cost of the institution highly controversial because of it. Return to text.
  4. Hall. massagetherapy.bc.ca. 2009. Return to text.
  5. Loken et al. Nature Neuroscience. 2009. Bio-medicine.org reports: “Nerve signals that tell the brain that we are being slowly stroked on the skin have their own specialised nerve fibres in the skin. The discovery may explain why touching the skin can relieve pain.” This discovery is important to touch therapies, of course. It strongly implies that neurological responses to touch have considerable complexity. Return to text.
  6. Shulman KR & Jones GE. The effectiveness of massage therapy intervention on reducing anxiety in the work place. Journal of Applied Behavioral Science. 32:160-173. Return to text.
  7. Cady SH, & Jones GE. Massage therapy as a work place intervention for reduction of stress. Perceptual & Motor Skills. 1997;84:157-158. Return to text.
  8. Hernandez-Reif M, Field et al. High blood pressure and associated symptoms were reduced by massage therapy. Journal of Bodywork and Movement Therapies. 4:31-38. Return to text.
  9. Richards, KC. Effect of a back massage and relaxation intervention on sleep in critically ill patients. American Journal of Critical Care. 1998; 7:288-299. Return to text.
  10. Complete lists of studies published by the Touch Research Institute. Return to text.
  11. The Touch Research Institute has conducted about one hundred studies showing the positive effects of massage and touch therapies. I am mistrustful of such consistency. It seems likely to me that the Touch Research Institute designs studies in such a way that a positive spin on touch therapy is inevitable. Also, conclusions in the abstracts of these papers are often so broadly stated as to be uninteresting: one of their studies concludes, for instance, that the subjects “report satisfaction.” People are often satisfied with snake oil — that doesn’t mean it works! As such, in my own reading, I have taken Touch Research Institute papers with a grain of salt: not to be ignored, but not to be taken too seriously either. Return to text.
  12. Field T, Hernandez-Reif M, et al. Juvenile rheumatoid arthritis: Benefits from massage therapy. Journal of Pediatric Psychology. 1997;22:607-617. Return to text.
  13. Wilkie DJ, et al. Effects of massage on pain intensity, analgesics and quality of life in patients with cancer pain: A pilot study of a randomized clinical trial conducted within hospice care delivery. Hospice Journal. 2000;15:31-53. Return to text.
  14. Field T, et al. Autistic children's attentiveness and responsivity improved after touch therapy. Journal of Autism and Developmental Disorders. 1986;27:329-334. Return to text.
  15. Kutner et al. Annals of Internal Medicine. 2008. This study showed that “massage may have immediately beneficial effects on pain and mood among patients with advanced cancer” and that it didn’t do much more than simple touch for cancer patients … but that they both helped patients. This is both a scientific blow for massage therapy, and a nice validation at the same time. It doesn’t say much for the ability of trained therapists to do any more for a cancer patient than a compassionate nurse. But it also reinforces the reassuring idea that any kind of touch is therapeutic, and that skill may not be a critical factor in the value of massage therapy to some patients. I’ve seen many cases over the years of amateurs who could give excellent massages simply by virtue of their empathy and attentiveness. Could massage “skill” be mostly just an extension of social (grooming) skills? Might be.

    Note that this research was significantly limited by all the usual things that make it so difficult to study the effects of massage therapy — for instance, we really have no idea what kind of massage therapy was done or what kind of training the therapists had, and it was unblinded, “possibly leading to reporting bias and the overestimation of a beneficial effect.” Nor did they even have a control group! (Yoiks.) Some science-savvy readers would consider these limitations so severe that they wouldn’t take the study seriously at all, but then again the results aren’t claiming much for massage therapy, and that in itself was interesting. Return to text.
  16. Mealy K, Brennan H, Fenelon GCC. Early Mobilization of Acute Whiplash Injuries. British Medical Journal. 1986;292:656-7. Return to text.
  17. McKinney LA. Early Mobilization and Outcome in Acute Sprains of the Neck. British Medical Journal. 1989 Oct; 299:1006-8. Return to text.
  18. My article, Mobilizing!, goes over this subject in much more detail and presents considerably more evidence. Early mobilization is one of the most umabiguous evidence-based recommendations a therapist can make. Return to text.
  19. Temporarily misplaced this reference. It will be filled in soon! — PDI Return to text.
  20. Studies contradict each other. A 1985 study by Zylbergold makes traction look good for neck pain, but a nearly identical study by Borman in 2008 came to the opposite conclusion. Two recent, good quality reviews of all such research have concluded that adequate evidence simply does not yet exist (see Graham and Graham). Return to text.
  21. Stratford PW, Levy DR, Gauldie S, Miseferi D, Levy K. The Evaluation of Phonophoresis and Friction Massage as Treatments for Extensor Carpi Tendinitis: A Randomized Controlled Trial. Physiotherapy Canada 1989 Mar-Apr;21(2):93-9. This is only one study of a complicated subject. Others certainly show benefit to frictions. Nevertheless, it is highly representative of the kind of controversy that makes it extremely difficult to make any strong claim about the efficacy of frictions. Obviously, we just don’t know! Return to text.
  22. Rosa et al. Journal of the American Medical Association. 1998. This paper is an entertaining chapter in the history of the science of alternative medicine: a child’s science fair project published in the Journal of the American Medical Association, showing that “twenty-one experienced therapeutic touch practitioners were unable to detect the investigator's ‘energy field.’ Their failure to substantiate TT's most fundamental claim is unrefuted evidence that the claims of TT are groundless and that further professional use is unjustified.”

    Therapeutic touch practitioners could not demonstrate any ability to detect a person by feeling their aura, even though this is exactly what they claim to be able to do. The test made them look ridiculous. Return to text.
  23. Many students at my school were actually angry that things like therapeutic touch were even being taught. I recall some heated debate between students and administration about it. Return to text.
  24. Craniosacral therapy has never been studied properly; the science that does exist is firmly at odds with it; and it’s outrageously implausible that a therapist could have a significant and reliable therapeutic effect by lightly touching the skull and sacrum. For more information, see Does Craniosacral Therapy Work? Return to text.
  25. Furlan et al. Cochrane Database of Systematic Reviews. 2008. Return to text.
  26. Therapies that don’t really work tend to show precisely the opposite pattern: the better the test, the worse the result (because, of course, a useless therapy can’t impress you in a fair test). But in the case of research for low back pain, the results are strong even in the best of the studies done so far. And that’s how it should be. If a therapy works, it should be fairly easy to prove it. Return to text.
  27. Deyo et al. Spine. 1993. Return to text.
  28. Wall. Pain. 2000. Return to text.
  29. Massage Therapy: Riddled with quackery. Barrett. 2006. This article by Dr. Stephen Barrett expresses the opinion that scientifically unsupportable ideas are common in the profession of massage therapy. He avoids a blanket condemnation of the profession, arguing that “ordinary massage and the legitimate practice of massage therapy should not be categorized as quackery.” However, he writes, “many therapists make claims that go far beyond what massage can accomplish. And even worse, massage therapy schools, publications, and professional groups are an integral part of the deception.” A number of references are provided to support his view. I agree with almost every detail of the article and wrote a letter of support to Dr. Barrett, which is published as an addendum to it. That said, the article does conspicuously neglects important points that should fairly be said in favour of massage therapy, and it contains a few minor false statements. But I applaud the intent and embrace and welcome most of the criticism. I wish it weren’t mostly true, but I believe that it is. Return to text.
  30. Cambron et al. J Altern Complement Med. 2007. 10% of 100 patients receiving massage therapy reported “some minor discomfort” in the day following treatment. 23% reported unexpected, non-musculoskeletal benefits. This study is underpowered and does not rule out the possibility of rare and/or serious side effects of massage therapy. Return to text.
  31. Shoemaker JK, Tidus PM, & Mader R. Failure of manual massage to alter limb blood flow: Measures by Doppler ultrasound. Medicine and Science in Sports and Exercise 1997;1:610-14. Return to text.
  32. Hovind H, & Nielsen SL. “Effect of massage on blood flow in skeletal muscle.” Scandinavian Journal of Rehabilitation Medicine. 1974;61. Return to text.
  33. Wakim KG, et al. The effects of massage on the circulation in normal and paralyzed extremities. Archives of Physical Medicine. 1949;301:35-144. Note that this study compares a more vigorous sports massage style with more common Swedish petrissage techniques. Vigorous massage did indeed show significantly increased circulation! However, this technique is rarely used — the vast majority of Registered Massage Therapists in British Columbia rarely treat their clients with vigorous sports massage techniques, yet they still have a habit of claiming that massage increases circulation. Return to text.
  34. For more detail, see another article on SaveYourself.ca, You Can’t Beat DOMS! The myth of treatment for nature’s little tax on exercise, delayed onset muscle soreness (DOMS). Return to text.
  35. Day JA, Mason RR, & Chesrown SE. Effect of massage on serum level of beta-endorphin and beta-lipotropin in healthy adults. Physical Therapy. 1987;67:926-930. Return to text.
  36. Wiltshire et al. “Massage Impairs Post Exercise Muscle Blood Flow and "Lactic Acid" Removal.” Medicine & Science in Sports & Exercise. 2009. Full Abstract:
    PURPOSE: This study tested the hypothesis that one of the ways sports massage aids muscle recovery from exercise is by increasing muscle blood flow to improve "lactic acid" removal.
    METHODS: Twelve subjects performed 2 min of strenuous isometric handgrip exercise (IHG) at 40% maximal voluntary contraction (MVC) to elevate forearm muscle lactic acid. Forearm blood flow (FBF; Doppler and Echo ultrasound of the brachial artery), and deep venous forearm blood lactate and H concentration ([La-], [H]) were measured every minute for 10 min post-IHG under three conditions: Passive (passive rest), Active (rhythmic exercise at 10% MVC), and Massage (effleurage and petrissage). Arterialized [La] and [H] from a superficial heated hand vein was measured at baseline.
    RESULTS: Data are mean +/-SE. Veno-arterial [La] difference ([La]v-a) at 30 s post-IHG was the same across conditions (mmol/L; Passive 6.1 +/-0.6, Active 5.7 +/-0.6 mmol/L, Massage 5.5 +/-0.6, NS), while FBF (ml/min) was greater in Passive (766 +/-101) vs. Active 614 +/-62 (P=0.003) and vs. Massage 540 +/-60 (P<0.0001). Total FBF area under the curve (AUC; ml) for 10 min post handgrip was significantly higher in Passive vs. Massage (4203 +/-531 vs. 3178 +/-304, P=0.024) but not vs. Active (3584 +/-284, P=0.217). La- efflux (mmol; FBF x [La]v-a) AUC mirrored FBF AUC (Passive 20.5 +/-2.8 vs. Massage 14.7 +/-1.6, P=0.03 vs. Active 15.4 +/-1.9, P=0.064). H+ efflux (mmol; FBF x [H]v-a) was greater in Passive vs. Massage at 30 s (2.2 +/-0.4 e-5 vs. 1.3 +/-0.2 e-5, P<'0.001) and 1.5 min ( 1.0 +/-0.2 e-5 vs. 0.6 +/-0.09 e-5, P=0.003) post-IHG.
    CONCLUSION: Massage impairs La- and H+ removal from muscle following strenuous exercise by mechanically impeding blood flow.
    Return to text.
  37. Plus, this is not the kind of study where a large number of subjects is needed to be pretty suggestive. Of course, replication and more subjects are always a critical part of science. But the claim of detoxification is what we call a “brittle” claim — it breaks easily, because anything less than a clear positive effect is not enough to impress anyone. For brittle claims, even just a lack of effect is always news, because there should be a worthwhile effect, according to the claim. In this case the claim is that massage meaningfully reduces lactic acid … and in this experiment, it didn’t just fail to have an effect, it had the opposite effect. That evidence is definitely news, whether it’s proof or not. Return to text.
  38. Finding May Solve Riddle of Fatigue in Muscles. Kolata. 2008. One of the great unanswered questions in physiology is why muscles get tired. The experience is universal, common to creatures that have muscles, but the answer has been elusive until now. Scientists at Columbia say they have not only come up with an answer, but have also devised, for mice, an experimental drug that can revive the animals and let them keep running long after they would normally flop down in exhaustion. For decades, muscle fatigue had been largely ignored or misunderstood. Leading physiology textbooks did not even try to offer a mechanism, said Dr. Andrew Marks, principal investigator of the new study. A popular theory, that muscles become tired because they release lactic acid, was discredited not long ago. Return to text.
  39. See What Happened To My Barber? Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers. Return to text.
  40. Ernst E. Massage therapy for low back pain: a systematic review. Journal of Pain Symptomology Management. 1999;17:65-69. Return to text.
  41. Pope MH, et al. A prospective randomized three-week trial of spinal manipulation, trans- cutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain. Spine. 1994;19:2571-77. Return to text.
  42. Kalauokalani D, et al. Lessons from a trial of acupuncture and massage for low back pain: patient expectations and treatment effects. Spine. 2001;26:1418-24. Return to text.
  43. Trigger points are probably involved to some degree in most cases of low back pain, which makes them a great target for therapy. At the same time, other things can certainly be wrong in the low back, such as injuries and arthritis. Return to text.
  44. I learned virtually nothing about these topics in 3000 hours of training. 99% of what I know, I’ve learned through intensive post-graduate study — not just clinical experience. Return to text.
  45. Lucas et al. Clinical Journal of Pain. 2009. This paper is a survey of the state of the art of trigger point diagnosis: can therapists be trusted to find trigger points? What science has been done so far? It’s a confusing mess, unfortunately. This paper explains that past research has not “reported the reliability of trigger point diagnosis according to the currently proposed criteria.” The authors also explain that “there is no accepted reference standard for the diagnosis of trigger points, and data on the reliability of physical examination for trigger points are conflicting.” Given these conditions, it’s hardly surprising that the conclusion of the study was disappointing: “Physical examination cannot currently be recommended as a reliable test for the diagnosis of trigger points.” Return to text.
  46. For more detail, see another article on SaveYourself.ca, Modality Empires: A tradition of ego-driven treatment methods in manual therapy. Return to text.