SaveYourself.ca • Sensible advice for aches, pains & injuries
last updated 42 days ago, Dec 21st, 2011
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.
Oh, absolutely! I made my living selling massage therapy services for many years. However, an acknowledged bias and an honest attempt to be fair-minded can result in a valuable informed opinion, perhaps better in many ways than pretending to be objective.1 I intentionally going out of my way to be critical of massage therapy. I consider it an intellectual and ethical duty: health professionals must be self-critical, and critical of each other. That is how we improve.2
← That symbol means a link will open in a new window.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 may due primarily to the effects of pressure on “muscle knots,” a ubiquitous phenomenon and likely factor in many common pain problems. For instance, the best scientific evidence available so far indicates that massage is probably at least somewhat effective treatment for low back pain — virtually the only therapy that is.
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 be a good combination, if a patient can find the therapist. Unfortunately, in most jurisdictions, massage therapists lack even the most basic training in orthopedics and rehabilitation, and pseudoscientific beliefs and practices are rampant.
I saw a few chiropractors 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
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.
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?3
But logistics, economics, and devilish details get in the way. Not many scientists are 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. 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 generally enough to prove much. Another challenge is that “massage” can mean so many things that it’s hard to know what is even really being studied (lack of standardization of treatment).4
More technically and most seriously, massage research is plagued by a “stark statistical error”: the error of reporting statistical significance of the wrong thing, or the wrong comparison.5 Dr. Christopher Moyer is a psychologist, and a rare example of a real scientist — someone trained and expert in research methodology — who has chosen to focus on massage therapy:
I have been talking about this error for years, and have even published a paper on it. I critiqued a single example of it, and then discussed how the problem was rampant in massage therapy research. Based on the Nieuwenhuis paper, apparently it’s rampant elsewhere as well, and that is really unfortunate. Knowing the difference between a within-group result and a between-groups result is basic stuff.
That error afflicts massage research in particular for the simple, ironic reason that massage is so much “better than nothing” — patients tend to be satisfied with massage regardless of whether it has a medically effect or “active ingredient.” This makes massage study results seem much more medically impressive than they would be if you subtracted all that satisfaction, and other “nonspecific” effects.
All of this is so substantial that it is fair and reasonable to ask if we can really say much of anything about massage based on such incomplete and imperfect evidence. We can, in fact, but it all has to be done with our eyes wide open and a lot of qualifiers and hedging of bets. We can’t be certain of anything … but we can certainly be informed by the evidence so far.
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”6
Massage for low back pain is the most studied massage question, and the answer is fairly clear — it probably works at least a little. 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” that it “works” — that is, clinically significant therapeutic effectiveness for a good variety of health problems.
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.7 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 correct8; the idea is further supported by evidence that massage therapy reduces blood pressure910 and helps people to sleep, even when they are under the unusual stresses of hospital care.11 These are all unsurprising … and unremarkable. Relaxation is an important component of wellness, and I do not underestimate its value, but it is hardly curative. And, as many critics have pointed out, massage is a really expensive way to relax. A nap is also relaxing. If massage is to be considered more cost-effective a treatment for any medical problem than napping, we must establish that it does more — quite a lot more — than just mellow people out.
Many studies done by the Touch Research Institute12 — although almost certainly of generally low quality and strongly biased in favour of massage13 — show many other broadly defined modest benefits to massage therapy in a wide variety of circumstances, everything from arthritis14 to cancer15 to autism.16 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.17 (A more recent and better designed Korean study was even more encouraging, showing that massage was quite a bit more helpful for patients with the deep, grinding pain of bone cancer than simply receiving compassionate attention.18)
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.
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.1920 In fact, the evidence strongly suggests recovery from nearly any injury or surgery is greatly facilitated by early mobilization.21 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. 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.22 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.23 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.24 Some massage therapists “believe,” while many others believe it’s nonsense.25
Craniosacral therapy is another classic example — popular for decades, it is a touch therapy, not “massage,” and it has never enjoyed any respect from the majority of doctors or scientists, and has even been criticized by many alternative health professionals.26 And yet it is sold with great (over!) confidence by countless manual therapists as though it were proven effective.
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.
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 240 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 (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:27
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 quite well in these tests. And, better yet, the results were also positive in the more rigourous tests.28
The largest study of massage for low back pain ever done was published in 2011, and its very credible authors — medical back pain experts Daniel Cherkin and Richard Deyo, in particular — did conclude that “Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months,” but those results were uncertain due to a major flaw, and somewhat overstated.29 It seems to me that the results actually damn massage with faint praise. If massage is good for back pain, shouldn’t the results have been a more a bit more impressive? Despite its “positive” results, this study is a bit of a mood dampener.
So, is massage therapy for low back pain “proven” to be effective? Ha! Obviously 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.
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.”30
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.”31
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.”32 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!
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 patients33 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:
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, certainly not consistently.343536 It’s just kind of a silly claim — it doesn’t even matter if massage increases circulation a little: even a consistent modest boost would be clinically trivial, dwarfed by the effect of even a small amount of exercise. Metabolic demand is the primary driver of circulation.
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 physiology 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.37 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.38 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.
And now for a bit of random massage humour:
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.39
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.40
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.41 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 causes42).
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.
Another serious general concern about the quality and effectiveness of massage therapy is that their is so much emphasis placed on “technique.” It is especially troubling that so many branded techniques are taught in place of genuine continuing (academic) education and hyped as “advanced,” even though they are all unproven, disproven in many cases, and generally based on shoddy clinical reasoning. This is the serious problem of certification rackets or “modality empires” — selling credibility to therapists in the form of certifications for a treatment method. These techniques are proprietary and profit-motivated, and usually championed and promoted by a single entrepreneur who gets treated like a “guru” and has legions of dedicated followers (who tolerate criticism rather poorly).
Both therapists and patients get ripped off by modality empires. I cover the topic of modality empires in a separate article: Modality Empires.
Most of the major modality empires are based on a basic guiding principle or school of thought I call “structuralism” — an excessive preoccupation with biomechanical and postural factors in pain problems, a.k.a the biomechanical bogeymen. Structuralist techniques are all fixated to some degree on straightening or improving your meat, because they believe that you are crooked or unbalanced in some way. The entire school of thought has little merit. It is debatable at best and debunked nonsense at worst. This is another topic I have covered in (great) detail in another article: For more detail, see another article on SaveYourself.ca, Your Back Is Not “Out” and Your Leg Length is Fine: The story of the obsession with crookedness in the physical therapies. .
There are dozens of lines of evidence showing that structural treatment concepts of all kinds have failed to deliver the goods over the decades (see the structuralism article). But one recent large study of massage — the big back pain one described above (Cherkin) — produced particularly clear evidence that structuralist-style massage does not work. (And yet again, there’s an entire other article covering this in greater detail: the remainder of this section is just a summary.)
Researchers compared the effects of garden variety relaxation massage — classic Swedish — with allegedly more advanced “structural” massage, consisting of an assortment of typical treatment methods. The results were the same, showing clearly that a typical selection of structuralist massage techniques was not one stitch more effective than simple relaxation massage.
A course of relaxation massage, using techniques commonly taught in massage schools and widely used in practice, had effects similar to those of structural massage, a more specialized technique.
All that pretension. All those assumptions and lovely-sounding structural theories. All those expensive technique workshops those therapists went to, and all the extra money they charge real patients for their “expertise” to help pay off their investment in the workshops. It all added up to … nothing. They could have done relaxation massage instead and their patients would have been just as well off.
These results make typical so-called advanced massage really look bad, and they make the popular modality empires and structuralism as a paradigm look just ridiculous. The technique gurus push and sell the idea that their methods are dramatically more effective than humble Swedish. If they were even half-right, these “advanced” therapists should have gotten results at least 50% better than their lesser-trained comrades — not just better by a statistically significant margin, but much better, impressively better, decisively better, undeniably better, argument-stopping better, better with bells on …
Instead, it’s like the New York Yankees accepted a challenge from a beer league softball team and couldn’t do better than a tie score.
The gap between the pretension and carefully measured results is a nasty condemnation of a huge chunk of an industry, at least half of all massage the way it is actually being practiced (probably much more). Not good!
The evidence shows that massage can help low back pain, and yet the world has certainly 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.434445 What’s actually surprising is that massage even works as well as it does.
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.46
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.47
For instance, therapists are unable to reliably diagnose trigger points48 — 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.
A pleasant, relaxing experience may have any number of minor therapeutic benefits — such as bringing your blood pressure down — as discussed above. However, the subtler benefits of massage probably extend well beyond that, into the territory of emotional and psychological benefits that are virtually impossible to define or measure.
Intense and/or novel sensations can be a catalyst for personal growth, which is another reason why massage may be a valuable service regardless of what other effects it does or does not have on tissues or pathologies. Whether it is the clear goal of therapy, or simply a natural side benefit, the sensations of massage can change your sense of yourself, how it feels to be in your skin, and perhaps bump you out of some other sensory rut — which may give you some leverage on your emotional ruts.
It is a well-established fact of neurology that posture and facial expressions are strongly coupled to emotional state. It is likely that this phenomenon extends to the physical manipulations of massage: that being manipulated doesn’t just feel pleasant, but also has much more complex effects on emotions and cognition. And personal growth and emotional maturation probably have some clinical relevance to recovery and healing. See The art of healing by growing up.
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, 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.
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.
Wednesday, 21 December, 2011 — Added a list of “awkward questions” to demonstrate how hard it is to study what you can’t define. Also a few tweaks of related content.
Friday, October 28, 2011 — Added reference to a new article explaining common statistical errors that particularly afflict massage therapy research. Thoroughly revised the section, “The trouble with studying massage,” right near the top of the article.
Tuesday, 4 October, 2011 — Added reference to new research showing that massage therapy probably helps bone cancer pain.
Friday, August 26, 2011 — New section: “Personal growth: a massage benefit that may be impossible to define or measure.”
Friday, August 12, 2011 — Updated several references, and added an important new one about massage for low back pain, which also spawn an entire new section about the failure of supposedly “advanced” massage techniques.
Thursday, July 14, 2011 — Added an amusing video about massage.
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.
A dense text, important reading for professionals. This is an important book: offering hope and practical, effective self-treatment tips to countless people suffering needlessly from pain that doctors have failed to diagnose. Unfortunately, Davies also makes it sound like trigger point therapy can cure anything. The ultimate myofascial pain syndrome reference, the product of decades of extraordinary dedication by two doctors famously devoted to the subject of soft tissue pain. The two-volume set is also brilliantly illustrated. The introductory chapters constitute an excellent overview of the subject, albeit a dauntingly technical one. Note: although a landmark and important text, more recent information has been published in Muscle Pain: Understanding Its Nature, Diagnosis and Treatment by Siegfried Mense and David Simons. This is essentially a physiology textbook with imagination and a soul. It’s a hard read, but equally rewarding. And the introductory chapters of this book do a better job of explaining some of the possible subtle benefits of massage therapy than anything else I’ve ever read. Read an excerpt.The research and subsequent change in some massage beliefs is not to make therapists feel belittled or inferior … it’s about making us more knowledgeable, therefore making us more professional and better respected.
— Choice Kinchen, massage therapist, Your First Choice Massage, Midvale, Utah
This is exactly the right idea and the right spirit. It is not expressed nearly often enough, or firmly enough. If massage therapy is to be taken seriously, then massage therapists must take science, research and continuing academic education seriously. There is no room for amateurism in health care.
BACK TO TEXTIt is hard to study what you can’t define… and it is extremely difficult to define massage precisely. Many possible questions arise! What kind of massage therapy? What methods? Could a combination of methods be effect where another combination fail? How well trained is the therapist? Are “advanced” technique better than relaxation and Swedish techniques? Or maybe the basics are the basics because they really work? How much massage therapy? Could 5 sessions succeed where 2 would fail? Is one appointment “massage therapy,” or does it really need more? Could 9 sessions actually be better still? Or perhaps counterproductive? Can anything be done with short sessions, or are long ones needed? If massage works, how much of the benefit can be attributed to non-massage elements like bedside manner, relaxation, and reassurance? How much do those factors define massage? What if massage didn’t work at all, or very poorly, without them? Would that mean “massage” works because it’s a great way of delivering a nice experience? Or that nice experiences “work” and the massage is irrelevant? What if massage therapy of a certain type for a specific condition was only effective 20% of the time? 60%? 80%? At what point is it “worth a shot”? (And worth the expense?)
Efficacy of “massage therapy” just cannot be meaningfully evaluated as a whole — it is just too broad and flexible a term.
BACK TO TEXT Comments: 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. BACK TO TEXT Abstract:BACK TO TEXTThis study evaluated the effectiveness of a 15-min. on-site massage while seated in a chair on reducing stress as indicated by blood pressure. 52 employed participants' blood pressures were measured before and after a 15-min. massage at work. Analysis showed a significant reduction in participants' systolic and diastolic blood pressure after receiving the massage although there was no control group.
Comments: Conclusion: “Back massage is useful for promoting sleep in critically ill older men.” BACK TO TEXT BACK TO TEXT BACK TO TEXT BACK TO TEXT BACK TO TEXT Comments: From the abstract: “Results showed that eight weeks after the accident the degree of improvement seen in the actively treated [early mobilization] group compared with the group given standard treatment was significantly greater ....” BACK TO TEXT Comments: From the abstract: “Advice to mobilise in the early phase after neck injury reduces the number of patients with symptoms at two years and is superior to manipulative physiotherapy. Prolonged wearing of a collar is associated with persistence of symptoms.” BACK TO TEXT Comments: 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.”
BACK TO TEXT BACK TO TEXT Comments: 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. BACK TO TEXT BACK TO TEXT Comments: 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. BACK TO TEXT Comments: 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 12 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.”
BACK TO TEXTOne 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.
Comments: This is a review of four studies, all of which were burdened with “major methodological flaws,” and concludes that “Massage seems to have some potential as a therapy for LBP. More investigations of this subject are urgently needed.” (Such as the large study finally published in 2011: see Massage Therapy Kinda, Sorta Works for Back Pain.) BACK TO TEXT BACK TO TEXT Comments: 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.” BACK TO TEXT
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