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? Can massage therapists rub out sore “trigger points”? Massage is a popular treatment for tough, common pain problems like low back pain, neck pain, and headaches — but can it provide meaningful change, or does it just pleasantly distract patients and maybe take the edge off? In this article, I examine massage therapy in the light of science — not “objectively,” but fairly.1 I go out of my way to be critical of my former profession — I consider it an ethical duty. Health professionals must be self-critical and critical of each other: that is how we improve.2
This article is curmudgeonly and cynical in many ways, but I also still recommend massage therapy. It has some plausible medical benefits, even if they are inconsistent and unproven. More importantly, the emotional value of touch and the effects on mood and mental health are so profound that patients really just cannot lose — good quality massage therapy is a worthwhile service for anyone who can afford it whether it “works” as a treatment or not. There are many ways that ethical, progressive, science-respecting massage therapists can thrive in their profession despite the fact that it is quite badly polluted with myths and quackery. See Reassurance for Massage Therapists.
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, p. 115
There are a few “medical” massage therapists out there with some more substantive training in orthopedics and rehabilitation, a couple years worth, with certifications that mean something. In general, these are the “licensed” or “registered” massage therapists, although the standards vary widely. Two years of training isn’t exactly like going to medical school, and it doesn’t even come close to what physical therapists or chiropractors and some osteopaths do, but it is well above average for massage. A massage therapist with this level of education is certainly the kind that patients should seek out if they want massage as a treatment for anything.
Unfortunately, such massage therapists are rare. Many LMTs and RMTs have much less training than others, and massage therapists in most places in the world are barely trained and entirely uncertified. Most work in spas or resorts and on cruise ships, doing treatments that are notoriously 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). If they continue their educations at all, they do so by taking weekend workshops in branded methods of extremely low average quality. It’s actually inappropriate to call these practitioners “therapists” at all, and in some places (here) it’s actually illegal — they have to use terms like “bodyworker” or “masseuse.”
Some therapists see themselves as medical professionals, despite their brief training and generally low medical and scientific literacy. But most — even the better trained ones — are alt-med partisans, ideologically opposed to “western medicine,” and prone to outrageously flaky beliefs.3 The profession is amateurish and pseudoscientific — barely a healthcare profession at all.
If medical doctors saw even a tenth of the discussions on some of the FB massage groups, they would never take us seriously enough to refer a patient to any of us.
Laura Allen, Massage Therapist, author of Excuse Me, Exactly How Does That Work? Hocus pocus in holistic healthcare
And yet some of the most pleasant massages I have ever had were also done by therapists of this type! Compassionate 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 does. That said, many of them cannot resist promoting their beliefs during a session — “Have you tried a colonic cleanse?” — which is a deal-breaker for me.
The other “manual therapists”: chiropractors, osteopaths, and a few physiotherapists
A few physiotherapists, some chiropractors, and quite a few osteopaths also “dabble” in massage, and a few even devote their careers to it. Together, all of these professions are often referred to as the “manual therapies,” because they are unified by an interest in helping people with hands-on manipulation of tissues, especially joints and muscles.
To most patients, osteopathy is indistinguishable from chiropractic but whereas chiropractic is much more focused on joint manipulation, osteopathy has always been more interested in the manipulation of both joints and muscle.4 Osteopathy and physiotherapy both involved a fair bit of massage therapy “before it was cool,” before massage therapy emerged as a distinct profession. Osteopathy is also the profession that produced craniosacral therapy, a modality practiced by many massage therapists.
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I have seen this old gem of a comic strip shared off & on for years. It was published in 2007 on Phil Selby’s blog “The Rut,” defunct since 2013, but still online at BigEyeDeer.WordPress.com. Mr. Selby does not appear to be active online today. Wherever he is, I raise a glass to him for this fine bit of nerdery.
Most massage is Swedish massage, which is mostly about lubricated kneading of muscle, and a few other clichéd techniques. Swedish methods are remixed extensively into a variety of styles, like relaxation massage versus sports massage, and even the culturally distinctive massage styles, like Thai massage or Hawaiian lomi lomi, are very similar to Swedish in principle.
These “styles” are just variations on a theme and not really what mainly defines different types of massage therapy.
Despite its prevalence and popularity, many massage therapists look down on Swedish massage as too “basic.” They aspire to do massage for different reasons, with more “advanced” techniques that have different purposes. They get those techniques almost exclusively from a parade of gurus in the field who claim to have “advanced” techniques that are more effective.
Those modalities are mainly what define various types of massage.
A serious general concern about the quality and effectiveness of massage therapy is that there is so much emphasis placed on specific, branded “techniques” and styles. The massage world is fragmented into dozens or even hundreds of these, depending on how you count. It is especially troubling that so many proprietary techniques are hyped as “advanced” and taught in place of genuine continuing (academic) education. 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 tend to get ripped off by this system. For more information, see Modality Empires: The trouble with the toxic tradition of ego-driven, trademarked treatment methods in massage therapy, chiropractic, and physiotherapy.
Is there any evidence that any of these allegedly advanced techniques actually work better than ordinary Swedish massage? No. They are all unproven (no exceptions), and mostly based on shoddy, self-serving clinical reasoning, especially obsolete ideas like “structuralism” (an excessive emphasis on anatomical assymetry and other alleged biomechanical bogeymen). We can’t even start to judge any of the lesser massage techniques based on the results of good tests (that is, careful comparisons with other treatments, and fake treatments, to see what works best). Such data is thin even for the most prominent massage modalities, and the rest have not been studied at all, or so poorly that it barely counts (eg: “tensegrity-based massage”).
For now, and maybe forever, we can only judge these methods on the basis of the the strength of their defining idea. What’s different about it from other common massage methods? Anything? What can it do that supposedly other techniques cannot? You’d be surprised how many barely count as more than a slight variation on Swedish massage. Even if it is distinctive, is the big idea any better than a pet theory? Most are not. The history of medicine is littered with the corpses of pet theories. Most treatment ideas do not work out (null hypothesis), even really good ones.
And almost everything that is worthwhile about massage is probably thanks to being artfully touched, which you can get from almost any method. I explore the “magic” of touch therapy in an old essay about why I became a massage therapist in the first place, and it will come again a few times in this article.
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Massage therapists choose from literally hundreds of different ways of trying to help people with their hands, and many of these ways 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 for certain things, but the overall usefulness of this mish-mash of techniques is hard to know.
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.56 In fact, the evidence strongly suggests recovery from nearly any injury or surgery is greatly facilitated by early mobilization. But “massaging with movement” is not “massage therapy,” of course — it’s something that a few well-trained massage therapists prescribe, and only in specific circumstances.
Lymphatic drainage is an interesting example of a specific massage technique, allegedly good for one thing and not much else: its purpose is to reduce swelling. By reputation, it’s the best treatment option for patients suffering from lymphoedema, a serious complication of mastectomy and other surgical procedures. But it’s also obscure, technical, and practiced by no more than a few hundred therapists globally. It’s not “massage therapy” per se; just a specialized tool that a tiny group of professionals specialize in, some of whom happen to be massage therapists. Oh, and bad news: there’s also recent evidence that it does not work,7 or not nearly as well as we’d like.8
Spinal traction is 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 a mess.9 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. I discuss traction in considerable detail in both my neck pain and back pain tutorials.
Friction massage, another specific type of massage, mainly as a treatment for tendinitis,10 was pioneered by physiotherapists and adopted unquestioningly by massage therapists. Unfortunately, although it’s a reasonable idea, it has yet to be satisfactorily supported by the evidence (undermined by it, if anything11). Yet the profession clings to friction massage, mostly due to the assumption that it must be good if better-trained physical therapists do it — which is not a safe assumption.12
As dubious as these methods are, 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.13 Some massage therapists believe, while many others believe it’s nonsense.14
Craniosacral therapy is another classic example — popular for decades, it is a touch therapy, not “massage” per se. It has never enjoyed any respect from most doctors or scientists, and has even been criticized by many alternative health professionals.15 And yet it is sold with overconfidence by countless manual therapists as though it were proven effective.
Hydrotherapy and other spa treatments. Thanks to the long association between massage therapists and spas, things like salt scrubs, mud wraps, and contrast bathing were actually a part of my training (and largely a waste of time and tuition fees). Heating pads and ice packs are clichés of rehab, and I actually rather like those for some purposes, along with a handful of related techniques — but the majority of “hydrotherapies” are quaint, impractical, and of no clear medical value.
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This awful infographic I noticed making the rounds on Facebook basically claims that massage therapy can do aaaaaanything for people’s health:
The evidence does support massage for anxiety and depression, which is important (much more on this below). Other than that, though, these bullet points range from “exaggerated” to “delusional.” The image was inspired by this equally terrible blog post, which uncritically celebrates and exaggerates the conclusions of few dubious sources, boosterism clumsily masquerading as science blogging, and fooling everyone who wants to be fooled — which isn’t all massage therapists, but certainly a lot of them.
The sad truth is that massage therapy has almost no significant proven medical benefits and is burdened with an embarrassing number of myths and a history of amateurish research. Massage therapists are hardly alone in this: the entire field of musculoskeletal medicine is generally scientifically improverished and lagging well behind most of the rest of evidence-based medicine (EBM). For instance, physical therapy, a profession with much higher scientific literacy on average, is also plagued with myths, junky science, and pseudo-quackery.16
Medicine has had bigger, scarier fish to fry than treating mere aches and pains and injuries.17 And it still does. Even sports medicine, with its vast resources, is still surprisingly primitive. By comparison, massage research is a depressing backwater.
I’ll explain the myths and review the science, such as it is. While there is much debunking to be done ahead, I’ll begin with the positive: some of the legitimate reasons why massage research is so difficult and limited — excuses, excuses! — and the best scientific case that can be made for massage therapy to date.
Nostril yanking therapy: “nasal work” and “cranial work”
Actual reader question: “Why would a bodyworker yank painfully on my nostrils?”
Why indeed! My answer: pure therapy theatre. Specifically, a melodramatic clinical gesture intended to impress patients with the therapist’s creative, eccentric wisdom, and exotic skill… but which is, in fact, utter bollocks. 🙄 This kind of thing is disturbingly common in massage therapy, and the nose yanking was popularized by one of the major massage modalities, Rolfing, where it is pretentiously called “nasal work,” one part of “cranial work.” Arguably this technique is the apotheosis of bullshit in massage, the most egregious and common type. The rationale for it is delusional nonsense,18 but it is particularly dependent on fascia pseudoscience. More on that coming soon.
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?19
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, 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).20
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.21 Dr. Christopher A. 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 medical 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.
There is so much uncertainty 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 must 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”22
(Dr. Moyer thinks it’s even worse than “in its infancy” — he’s called massage therapy research “stunted”!23 Nevertheless, let’s make of it what we can … )
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Massage for low back pain is the most studied massage question, but not enough: the answer is still “more study needed.” Massage for trigger points is also relatively well studied, but also not enough: science has still yet to confirm that pushing on sore spots makes them less sore. I discuss both of these in detail in their own sections below.
And that’s where the evidence is the most plentiful and relevant to what people want from massage.
Most other evidence about massage benefits is indirect and/or so weak it’s meaningless. For instance, there are a few scraps of evidence — not nearly enough, but better than nothing — that rubbing and stretching soft tissue can reduce joint pain and stiffness.24 (Note that stiffness is a symptom, a sensation of discomfort with movement with many possible causes and which may or may not involve any actually limited movement. See Why Do Muscles Feel Stiff and Tight?)
Some research helps us to understand why people like massage, or why it’s likely that there are numerous minor or general health benefits. But there are no smoking guns, no “proof” that it “works,” no clear evidence of clinically significant therapeutic efficacy for any health problem, let alone a meaningful variety of them.
The power of touch
Basic research has shown that touch is neurologically complex and probably has many physiological effects. Skin is fantastically rich in nerve endings — up to about 10,000 per square centimetre25 — and in 2009, Swedish researchers identified specialized nerve fibers that respond only to light stroking of a certain speed.26
Massage therapy is particularly chock full of triggers for autonomous sensory meridian response (ASMR) — a rush of euphoria and tingling that is probably positive reinforcement for grooming in the same way that orgasm is evolution’s way of encouraging reproduction: a primal satisfaction. It likely goes beyond just being a nice, weird feeling: it either has predictable effects on mood and physiology (or it correlates with such changes), and therefore may well also offer actual “therapeutic benefits for mental and physical health.”27
These things shed some specific scientific light on the obvious: massage can be a rich and novel sensory experience, which can in turn be a major mechanism for therapeutic benefits and even pain relief specifically. If massage works, it’s probably mainly because of the neurology of touch (as opposed to, say, changing tissues).28
For instance, we know that chronic pain in particular tends to get increasingly disconnected from reality (sensitization), and safe, pleasant, interesting sensations may help us get back on track.2930 Such a benefit is both highly plausible and highly speculative. Sadly, there is an absence of useful evidence on the topic. We know many chronic pain patients are drawn to massage like bees to flowers, but we don’t know how much relief is actually possible.
Another interesting indirect example: stretching massages muscles with movement, and so it may feel good for some of the same reasons and share some of the same benefits. And indeed a 2011 study of simple, static stretching showed a clear, good effect on heart rate regulation31 — just from pulling on muscles, which may not be very different from pushing on them. It’s not much of a leap to guess that rubbing soft tissues could also have systematic regulatory effects.
Many studies done by the Touch Research Institute32 — although almost certainly of generally low quality and strongly biased in favour of massage33 — show many other broadly defined modest benefits to massage therapy in many circumstances — everything from rheumatoid (bad) arthritis34 to cancer35 to autism.36 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.37 (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.38)
But all of that is both vague and uncertain. Is there firmer ground?
The most evidence-based benefit of massage: reducing depression and anxiety
While many benefits of massage are still disconcertingly uncertain and hotly debated (by some), there are two that can be considered “proven.” Massage researcher and psychologist Dr. Christopher explains that the only confirmed benefits of massage are its effects on mood (“affect”),39 specifically:
- massage reduces depression
- massage reduces anxiety
This is a big deal. One does not simply reduce pull a reduction in anxiety/depression out of thin air — it is bound to be just the measurable part of a complex web of psychological effects and benefits. I will dive deeper into the psychological power of touch below.
Dr. Moyer believes that more importance should be placed on these effects, and that they should even be the basis of “a new subfield for MT research and practice: affective massage therapy (AMT).”
Building on what is already known about the effects of massage therapy on anxiety and depression, everything possible should now be done to better understand and to optimize the ways that massage therapy influences affect, the observable components of an individual’s feelings, moods and emotions.
Christopher A Moyer
Perhaps one of the reasons massage reduces depression and anxiety is that it’s simply relaxing. While not proven as well as you might think, it is a pretty safe bet,40 and the idea is further supported by evidence that massage therapy may reduce blood pressure4142 and helps people to sleep, even when they are under the unusual stresses of hospital care.43 These are all unsurprising … and unremarkable. Relaxation is an important component of wellness and pain management, and I do not underestimate its value, but it is hardly curative.
Many critics have pointed out that massage is an extremley expensive way to relax. A good way, to be sure, but costly. On average, professional massage therapists charge about a buck a minute — vastly more than millions of people can afford on a regular basis. This economic perspective is often completely ignored in discussions of whether or not massage works. It probably does in some ways for some people… but well enough for the price? A nap is also quite relaxing, and a lot cheaper. If massage is to be considered a more cost-effective treatment for any medical problem than napping, we really must establish that it does more — quite a lot more — than just mellow people out.
Massage is a super expensive way to relax. On average, professional massage therapists charge about a buck a minute. Naps are free.
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This topic is covered much more thoroughly in PainScience.com’s detailed low back pain tutorial. If you really want to understand massage for low back pain, that’s what you need to read. This is an abridged excerpt.
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’d guess that about 70% 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, 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! But no one actually knows if it does, because the evidence all boils down to this:
error! insufficient data!
For many years the best review of the science that was available, by Furlan et al., had a cautiously optimistic conclusion, declaring that “massage is beneficial.”44 But then, in 2015, Furlan et al. added another dozen studies to the pool of data, and actually changed their tune: now they have “very little confidence that massage is an effective treatment for LBP.”45 And nor should they. Although there are scraps of good news, the evidence damns massage with faint praise — just like all other “promising” back pain treatments.
Furlan et al.…
… in 2008: “massage is beneficial”
… in 2015: “very little confidence that massage is an effective treatment”
The change from optimism to pessimism is fascinating, and caused some angst in the small community of massage therapists who pay attention to research.46
Furlan et al. suffers badly from the “garbage in, garbage out” problem. It was not a tidy apples-to-apples review, not by a long shot. Most of the studies had almost little in common except that they were all experimenting with some kind of massage-like therapy for some kind of back pain. It is not remotely conclusive.
Sometimes “more study needed” is a bullshit cover for the fact that the research so far has simply failed to produce the good news that someone wants, but sometimes more study really is needed, and I think this is a great example.
Can I cherry pick my way to a happy ending?
What do the best studies say? One of the best, a Canadian experiment conducted by Michele Preyde way back in 2000,47 was a test of “comprehensive massage therapy” as delivered by well-trained Ontario therapists,48 in six sessions in a month for 25 cases of sub-acute low back pain (non-chronic, but not brand new cases either). This treatment regimen was compared to massage alone, remedial exercise and posture education alone, or some useless laser therapy. Massage alone had “considerable benefit,” just enough to be considered clinically significant; adding exercise prescriptions (and posture education, but that probably wasn’t a difference maker) improved on those results even more, pushing them comfortably into clinical significance.
Sounds great, right? But it has a critical flaw: the frustrebo effect, a “frustrated placebo,” caused by a lack of blinding. That is, everyone recruited for this study knew full well that it was a massage study … and so the folks assigned to the non-massage group were likely frustrated by that, which can cause a negative placebo effect.
The frustrebo effect is a great demonstration of how tricky science is.
This kind of thing is what happens to all the “best” studies when you look closely, including the largest ever controlled trial of massage for low back pain.50 It wasn’t blinded either, and their optimistic conclusion was at odds with their own data.51
So that’s two studies now that seem good but have serious flaws. If you do the homework, it turns out it’s actually impossible to cite any evidence that is clearly, unambiguously promising. And so the conclusion is still just null: science has yet to confirm that massage can help back pain, and it probably won’t for a long time.
Once again, this is all considered in much greater detail in my low back pain e-book.
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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 has often gotten a stamp of approval from medical experts. For instance, back pain expert Dr. Richard Deyo: although openly skeptical about most other back pain therapies, he acknowledges that “promising preliminary results of clinical trials suggest that research on massage should be assigned a high priority.”52
Patrick Wall, the eminent neurologist and pain researcher, writes only a single word about massage therapy in his seminal book about pain: “Delightful.”53
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.”54 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 massage therapists routinely sell and endorse virtually every imaginable form of alternative health care, including the silliest, things like ear candling, crystal therapy, iridology, gong therapy (look it up!) … you name it, there’s a goofy therapy that many massage therapists “believe” in. They are champions of the worst of alternative medicine.
But the approval of smart, critical experts does suggest that the healthcare value of massage itself is at least plausible — and that simply isn’t true of many other common therapies in the marketplace. In contrast, consider how much anti-quackery activists object to chiropractic, homeopathy, and naturopathy.
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Fibromyalgia is a condition of widespread body pain, severe fatigue, and mental fog. It’s existence used to be controversial, but no longer: it is a widely acknowledged phenomenon. Now the mysteries and controversies swirl around its nature and treatment. But it seems like a massage-friendly condition.
Massage is reputed to be helpful, and certainly many fibromyalgia patients seek it out (while others avoid it, finding it too intense and exacerbating). Like low back pain, it seems like massage should be able to help with fibromyalgia. Surely massage can help soothe the frazzled nerves of a uninjured patient whose primary symptom is pain? And if it can’t, what good is it?
A 2014 Chinese review of studies by Li et al55 is mainly a good example of what a shabby state massage therapy research is in. This paper proves nothing about massage; it’s straightforwardly inconclusive. It has a positive sounding conclusion that isn’t really justified and there are major caveats.
But it doesn’t mean that I wouldn’t go get me some massage if I had fibromyalgia. I probably would! But this is about the science, so here goes:
The massage therapy for fibromyalgia that epitomizes the “garbage in, garbage out” problem with meta-analysis. There was virtually no research on this topic worth analyzing to begin with. Trying to pool the results of several weak studies is basically meaningless. To the extent that the study results are generally inconclusive and ambiguous, the conclusions of any review are going to have more to do with the authors’ opinions and biases than hard data.
This review is somewhat novel in that it includes some Chinese research, but it doesn’t really help. The introduction curiously boasts that “traditional Chinese massage is one of the most ancient massage therapies,” but there is not enough distinctive about Chinese massage that makes it worthy of any focus, and massage is ancient in every culture. This weird, prominently placed statement is a red flag: biased interpretation ahead! (And only one study of traditional Chinese massage made it past the selection criteria anyway.)
Unsurprisingly, the conclusions here are superficially positive: massage “significantly improved pain, anxiety, and depression in patients with FM.” But that’s statistical significance only, not a clinically significant degree of improvement: the size of the effect is trivial (much smaller than amplitude of the noise in the data). As usual, using the word “significantly” this way is technically correct and defensible, but otherwise misleading to all but the most alert readers.
Also, the conclusion is based in large part on the data about depression and anxiety, which are likely to improve with massage regardless of any effect on fibromyalgia — the one truly evidence-based effect of massage, as discussed above.
And more bad news: despite the seemingly strong positive conclusion, the data is just silent on longer term effects. Only two studies had any follow-up data at all. Without promising data about long-term effects, it would be hard to say massage “works” even if the short term data were much more clearly positive.
Both sides of this research question are highly problematic: fibromyalgia is hard to diagnose or define, and massage is hard to study. Even using official diagnostic criteria, which changed significantly in 2010, there’s a lot of wiggle room. (As Fred Wolfe has put it, “One doesn’t either have fibromyalgia or not have it. There is a gradual transition from the mild to the severe. The point at which we classify an individual as having fibromyalgia is arbitrary, but reasonable.”) The types of massage reviewed here were generally vague and all over the map, from the straightforward (Swedish massage) to trendy-but-meaningless “connective tissue massage” (the idea of isolating or even emphasizing connective tissue in massage is a biological absurdity, like trying to eat the gristle out of a steak without masticating anything else) to rank quackery like “therapeutic touch” (which is literally not massage at all and roughly on par with believing in magic). What a mess.
So here’s my conclusion: whoop-de-doo. There’s really nothing here, except maybe massage for fibromyalgia being damned by faint, ambiguous praise. So does massage work for fibromyalgia? The only honest answer to the question is, “We don’t know, but probably not very well. Maybe for a few patients.”
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As far as I know, I only ever hurt one of my own massage therapy clients once: I was too aggressive too close to the cervical plexus, and did some nerve damage. That's not very easy to do, but I did it. In another article, I tell that story and explore the potential for nerve injury in detail.
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 patients56 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 …)
But serious injury is also possible, and for every dramatic case there are probably many minor versions of it that are never diagnosed or described in a scientific journal. For instance, in 2019, a man tore a five centimetre hole in his colon doing “hard” self-massage of his abdomen for constipation, and he could easily have died from that.57 Obviously that’s an exotically extreme case, but the implications worry me. How many people have had one-centimetre holes torn in their colons? Half centimetre? Or just severe bruising? While not life-threatening, such injuries are the opposite of helpful — and in addition to injury, they would also ironically increase constipation! Because the intestines stop contracting when traumatized, to protect themselves (intestional ileus).
These are real concerns that I think most people and most therapists are oblivious to. For the most part, no one is even asking if “deep tissue” massage might actually backfire. And it really might. In fact, I have quite fully fleshed out hypothesis that deep tissue massage may be causing an epidemic of undetected rhabdomyolysis. See Poisoned by Massage: Rather than being DE-toxifying, deep tissue massage may actually cause a toxic situation.
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Massage therapists, and others in the holistic arts … seem to be a particularly gullible bunch. And there are a lot of people who have seized upon that, and marketed their products, their classes, their modalities, and their wild claims to us … and many of us have fallen for it, hook, line and sinker … and unfortunately, gone on to convince our clients to buy into it, as well. … Our profession has turned into the snake oil medicine show.
Excuse me, exactly how does that work?, by Laura Allen
In addition to the many not-really-massage therapies that massage therapists may offer, there are also many claims that massage therapists make about massage itself that are all-too-questionable. The scientific case against massage largely consists of debunking the list of lame claims that define it to a surprising degree — and if you take them away, there’s not a great deal left. Most are just carelessly perpetuated minor myths. Some are not entirely or definitely wrong, but when presented to patients, are often misleading exaggerations and oversimplifications. For instance, massage probably does sometimes modestly increase circulation — just too little and too erratically to matter. It all adds up to a pattern of intellectual laziness in the profession that undermines its credibility and legitimacy.
Tightness matters. “You’re really tight” is a predictable phrase in massage therapy, but it’s mostly meaningless, or just illusory,58 and yet it is often the major rationale for therapy. Tissue texture correlates poorly with pain and other symptoms, and therapists have failed tests of detecting the painful side of low back or neck pain by feel59 — it’s actually an understandable and unimportant failure,60 but it also flies in the face of the popular mythology that therapists can zero in on tissue problems with uncanny accuracy. For more information, see You’re Really Tight.
Massage increases circulation. Massage therapists are particularly fond of claiming that massage “increases circulation,” but it doesn’t, really — certainly not consistently.6162636465 But it has always been kind of a silly claim, because it doesn’t really matter if massage increases circulation: even a modest boost would be clinically trivial, dwarfed by the effect of any amount of exercise. Metabolic demand is clearly the main driver of circulation. Also, the relaxation we get from any decent massage is directly at odds with increasing circulation: it powerfully shunts blood away from the muscles and into the core. That’s why it’s hard to get moving after! This is a complex topic that I’ve covered thoroughly in a separate article: Does Massage Increase Circulation? Almost certainly not in a clinically important way, and definitely not as much as even a small amount of exercise But the bottom line is that the effects of relaxation and exercise on circulation mostly render the claim irrelevant.
Massage detoxifies or flushes lactic acid from your muscles. Detoxification myths are among the most embarrassing of all massage myths. “Detoxification” sounds good and means little or nothing. There are such things as toxins in the world, but not only is massage unable to “flush” any that matter from the body, it likely produces a mildly toxic state known as rhabdomyolysis.66 But if you challenge massage therapists to name a “toxin” that they are “flushing,” most will name lactic acid, not rhabdomyolysis. And again, the truth is ironically the reverse of to the myth: evidence has actually shown that massage interferes with lactic acid elimination. See the lactic acid section below.
Massage treats delayed onset (post-exercise) muscle soreness. Supposedly, massage therapy can stop that awful soreness that develops after an intense workout, known as delayed-onset muscle soreness (DOMS) — which is ironic, because massage is also well-known to cause a little next-day soreness. Although some studies have shown that massage can take the edge off DOMS, that’s about as good as it gets67 — perhaps a 30% temporary pain reduction when the planets align. It certainly doesn’t restore your strength any sooner. As with increasing circulation, it’s important to maintain perspective: it wouldn’t matter much even if massage did cure DOMS. Although DOMS can be pretty unpleasant, it’s one of the most trivial of all pain problems, guaranteed to solve itself within three days. On a closely related note …
Fascia matters. Many massage therapists are selling “fascial therapy” to patients. The main idea is that fascia — sheets of tough connective tissue found throughout the body — can get tight and restricting, and needs to be “released” by pulling on it. Fascia science is considered an exciting frontier in manual therapy. Unfortunately, although some fascia biology is interesting, the stuff does not seem to have any properties that are actually relevant to healing and therapy. Key examples of fascia research either fail to support fascial therapy or actually undermine it. Enthusiasm about fascia seems to be an unjustified fad. See Does Fascia Matter? A detailed critical analysis of the clinical relevance of fascia science and fascia properties.
Some readers may not get this joke. It’s a reference to Pulp Fiction; it means, “I’m so sick of hearing about ‘release’ I might shoot the next person who says it.” The term has reached annoying buzzword status when paired with faddish excitement about fascia. While many therapists may find the frustration hard to understand, many professionals really are that fed up with hearing about fascia in general & release in particular.
Massage reduces inflammation. Um, no. The opposite, if anything.68 According to a sensationalized science news item in early 2012, supposedly massage “reduces inflammation” and “promotes muscle recovery.” But this was a small and technical gene profiling study, several steps removed from clinical reality, trying to explain a phenomenon that doesn’t clearly exist: we already knew that massage doesn’t do much for DOMS.69 All of the evidence about this and DOMS is explored in detail in a separate DOMS article.
Massage gives you an endorphin rush. The word “endorphin” reached buzzword 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 reduce pain by a variety of mechanisms, it probably doesn’t do it by putting more endorphins into the bloodstream.70 And, yet again, it wouldn’t be that big a deal even if it were true. Like relaxation, endorphins are good, but they can only do so much — at best, such an effect would mostly just explain the pleasantness of massage itself.
Massage reduces cortisol. This is a much more specific idea than “massage reduces stress.” Cortisol, the “stress hormone,” is justifiably perceived as a villain, and reducing it is often touted as a meaningful rescue from being run-down, chronically anxious or depressed, or in pain. Unfortunately, the evidence that massage actually does anything helpful to cortisol production is conflicting and inconclusive at best, and commonly cited research to support it has major flaws.71 Even in the unlikely event that massage actually does reduce cortisol levels, the physiology of stress is much too complex to assume that cortisol reduction is in itself a meaningful and good thing. Cortisol levels after a massage do not give a meaningful picture of the organism, and there is no direct relationship between a temporary cortisol reduction and any health benefit. What matters is cortisol levels over time, but even that isn’t exactly straightforward: stress and cortisol have a complex and chaotic relationship regulated by many variables out of our control.
And to conclude, a sort of “political” myth:
Massage must be good, because insurers pay for it. People assume that insurance companies are so savvy and parsimonious that they would never cover health services that weren’t effective. That’s almost better than science, right?! Follow the money! But insurance companies don’t have secret methods of determining the efficacy of unproven treatments. The industry has a long history of insuring the treatments people want; they get sucked in by the same hype that their clients are sucked in by, for competitive reasons. And yet, in spite of the popularity of massage, some insurers are starting to notice that it might not be a good value to pay for it.72
Rubbing acupuncture points can induce labour. This is a classic example of the Great-Power Gambit, in which alt-med practitioners self-servingly exaggerate their “great power” by emphasizing their “great responsibility” not to do harm.73 Massage therapists often earnestly warn each other and their clients not to rub certain acupuncture points because it might “induce labour” in pregnant women. No, it won’t. And the idea that it can — especially so easily that anyone needs to worry about it — is pure fanciful hubris. No normal massage can “induce” any labour that wasn’t already teetering on the edge anyway. The only people in danger of going into labour in a massage therapy office were in danger of it whether they were there for a massage or not. Also, even acupressure and acupuncture specifically intended to induce labour does not work.74
These myths barely scratch the surface: massage therapists say and believe many much more bizarre things, living up to their reputation for flakiness. Dozens of bizarre and hilarious example are compiled here: shit massage therapists say: A compilation of more than 50 examples of the bizarre nonsense spoken by massage therapists with delusions of medical knowledge. Which is in turn just a small slice of the larger problem of “therapy babble” in (mostly) alternative healthcare.
Despite all of this, massage therapists still have many reasons that they can feel proud of what they do, and many ways to practice massage therapy ethically and in an evidence-based way. See Reassurance for Massage Therapists.
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And now for 13 seconds of random massage humour:
And 48 seconds now. The title of the book he holds up — Massage Are Bollocks—cracks me up every time I watch it.
And here’s a much longer one — 8 minutes! — but worth every second, just for the opossum’s nonplussed reactions. But the therapist is a riot, and she effectively lampoons several of the goofier ideas in massage. She’s a genius.
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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 some means, usually described as flushing metabolic wastes from your muscles. Other “toxins” and unspecified metabolic wastes are often lumped into the myth, but lactic acid is by far the most famous and likely to get mentioned, so that’s what I’ll focus on here.
So, does massage “flush lactic acid”? This is not a hard thing to test — the principle is science-fair simple. Just compare metabolic waste products with and without massage involved. Researchers at Queen’s University in Kingston, Ontario, did exactly that in 2010.75
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. Goodness. That’s the opposite of what everyone wants to believe.
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.76 And then these findings were backed up in 2012 by a rather high-tech study.77 Massage does not reduce lactic acid levels.
In any case, the whole notion that you want or need to get rid of lactic acid in the first place is just bogus. Lactic acid is not the cause of muscle pain at any time. 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.78 In particular, lactic acid does not cause soreness the day after exercise — yet another myth, and a particularly bad one that will just not die!79
So presenting lactic acid as some kind of metabolic bogeyman that massage can purge from the flesh is 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 sometimes unethically done to rationalize adverse effects of therapy that actually have other causes, including potentially serious conditions.80
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, Burchat et al (CSMTA.ca)
Well, so much for controversy! Massage probably has many interesting physiological effects … but getting rid of acid in your blood is certainly not one of them. Nor is drinking extra water going to help. On the contrary, as mentioned above in the myths section, massage is probably modestly “toxifying,” not detoxifying. Other articles delving into detox myths:
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Although much rarer than post-event massage, some athletes also want massage before an event, and some therapists provide that service. The idea is mainly to stimulate and invigorate — a kind of warmup.
Unfortunately, it has always been implausible that massage before any kind of exercise/competition is helpful, and it’s not hard to imagine ways it could even backfire. For instance:
- A blast of novel stimuli can be surprisingly disorienting, even if it is also invigorating.
- There’s the phenomenon of post-massage soreness and malaise — any hint of that is obviously a problem for performance.
- Same with even a small amount of pain. Probably at least 10% of vigorous massages will cause some kind of discomfort,81 mostly minor and transient of course, but not what you want right before trying to perform!
When I was taught pre-event sports massage in school, I was actually warned to be quite cautious, because it really had the potential to throw an athlete off kilter. Proponents of sports massage are aware that things can go awry.
Evidence: massage probably won’t make you faster
There have been very few studies of pre-event sports massage. In 2018, a rare example of it had a clear negative conclusion,82 echoing the findings of a couple earlier ones.8384 It’s a very small study, but it’s still a useful contribution85 (and it’s not actually the first such evidence). Seventeen sprinters were tested with four combinations of massage, dynamic warmup, and an ultrasound placebo and found that “massage decreased 60-meter sprint performance in comparison to the traditional warm-up.”
Decreased. A traditional warmup was better.
Nick Ng has thoroughly described the study for Massage & Fitness Magazine, with lots of added value from an interview with the lead author, Dr. Ryan Moran. Good stuff. But the bottom line is simple: massaging before a sprint is extremely unlikely to be helpful.
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Foam rollers are so popular that they have taken on a life of their own, as if they are not “just” a delivery system for massage — different or even better than massage.
But foam rolling is in fact just a delivery system for massage.
The massage is the point. Pressure on tissue is the point. There’s nothing special about applying pressure to tissue in this way. It’s another way to massage yourself; it is no more (or less!) than a handy gadget that makes that easier. There are many slight variations on the theme, but their effects on tissue are biologically indistinguishable from pressure applied any other way. Any claim about any kind of foam rolling doing anything more effectively than any other kind of foam rolling is marketing hype. While there might be differences between rollers that make them feel nicer for some people, no one knows (or can know) that those subtle subjective differences make any objective difference (and it’s pretty unlikely).
Psychologically and emotionally, there are huge differences. Being massaged by another human being and massaging yourself with a glorified pool noodle are obviously completely different things. If there are any major differences in the efficacy of foam rolling versus massage, that’s it and that’s all: foam rolling is much more emotionally bland!
Not all foam rollers are made of foam. This one looks like it would probably get some good traction.
Foam rolling science … is a big fat nothing burger
Does foam rolling have measurable medical benefits? Something that general massage research hasn’t revealed? Of course not.
A 2019 review of studies was predictably inconclusive: just a classic garbage in, garbage out meta-analysis.86 It examined a couple dozen mostly poor quality little trials, all measuring different things in different ways, with no chance of adding up to a meaningful conclusion. To the extent that some studies showed some positive effects, they are small and unreliable, damned with faint praise. Science writer Alex Hutchinon (whose analysis I trust more than the authors):
My own conclusion after wading through the meta-analysis is basically a big shrug. If someone showed me this data and told me it was based on an exciting new pill, I’d tell them not to waste their money on the pill. It’s not convincing enough to win new believers. But neither is it damning enough to conclude that athletes definitely shouldn’t use foam rollers.
What about the single most promising data in the study, which showed a minor performance boost for rolling before sprinting? Alex again:
Of the four studies, two of them found essentially no effect, while one very small study found a positive effect that’s not significantly different from zero. So the conclusion that foam rolling boosts sprint performance is almost entirely based on a single study that disagrees with two others.
This is the exact opposite of “promising”: while technically just inconclusive, the absence of any robust benefit detected by any of these studies strongly suggests that better studies aren’t going to find much either.
Foam rolling and fascia
Fascial release is often cited as the point of foam rolling, as though foam rolling is uncommonly good at steam-rolling the kinks and wrinkles out of our connective tissues. This is just a fad mash-up: the fascia fad being used to justify the foam rolling fad.
Foam rolling is fine if you like the feeling, but the belief that it works by manipulating connective tissue is silly. Once again, foam rolling is just massage — and no kind of massage is known to have any important clinical effect on fascia (if any effect at all), and fascia doesn’t even have any problems that massage could plausibly correct. And even if it did have such an effect, it’s extremely implausible that foam rolling would work as well as massage, let alone better — as some rolling enthusiasts claim.
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A great many of the massage 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, AKA 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. This notion is easy to sell, but 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: Your Back Is Not Out of Alignment: Debunking the obsession with alignment, posture, and other biomechanical bogeymen as major causes of pain.
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 ridiculous. The technique gurus push and sell the idea that their methods are dramatically more effective than humble Swedish techniques. 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 the carefully measured results is a nasty condemnation of a huge chunk of an industry, of at least half of all massage the way it is actually being practiced (probably much more). Not good!
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So the imperfect evidence shows that massage can maybe 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 lots of back pain clients? 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:
- benefits are modest
- benefits are temporary
- benefits are inconsistent
It’s not surprising, then, that some studies show that low-back pain is not helped by massage therapy.878889 It’s actually surprising is that massage even works as well as it does.
I have a theory about what massage has going for it. Massage’s primary therapeutic effect on tissue and pain — if any — is not relaxation, toxin removal, or increased circulation, but instead some relief from muscle “knots” — myofascial trigger points. Modest relief. Temporary relief. Inconsistent relief.
But some relief. Your mileage may vary.
“Trigger points” are an awkward notion. They certainly describe a real phenomenon — sore, stiff, aching spots in muscles — but their true identity is unclear, and the science of trigger points is incomplete at best.
Trigger points may respond to massage, and that is certainly my impression from three decades of rubbing my own trigger points and trying to help other people with theirs. It’s also what legions of massage therapists believe. But don’t ask science for confirmation — it’s playing hard-to-get here. I get dorky in detail about the science of trigger point massage in the trigger points tutorial, but here’s the bottom line …
Trigger point masssage is still 100% experimental. It has rarely been directly tested and it has never been done well (and never for back pain specifically, which is probably of the greatest interest).90 If you squint optimistically, you could call the best of the evidence “promising.” You could say that where there’s smoke, there’s fire. But it’s like the smoke from last night’s campfire — more of a smokey smell than a smoke where any fire might be hiding. Dial up even a mild cynical impulse, and the evidence collectively looks more like a damning failure to produce any clearly good news.
But mostly there’s just no conclusion at all. Science just has no idea if it works.
But, done with humility, informed consent, and some caution, it can be a safe, cheap experimental treatment that is at least pleasing. Nothing in massage is more satisfying than a good trigger point rub: it is the ultimate example of whatever it is that makes people crave massage.
The phenomenon is common and particularly tends to crop up as a complication of many other kinds of painful problems. And so many such problems seem to 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.91
If this theory is correct, or even half-right, it would go a long way to explain the strong appeal of massage — maybe it actually can take the edge off a great variety of problems — 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 unpredictable. The best ways to treat trigger points are simply unknown, and it may be next to impossible. All trigger point therapy is guess work. 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.92
For instance, the average therapist is probably not even able to reliably find trigger points,93 and it is tricky to treat what you can’t find. Even when you have found them, we have no idea if they can actually be treated by any well-known method, none of which has ever been clearly shown to be effective. There are many kinds of treatments for 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 cripple another patient).
On the bright side
Any good quality general massage is probably better than bad trigger point therapy. There is plenty of overlap between decent trigger point therapy and an ordinary pleasant massage.
And hands-on experience is valuable, and anyone who’s had a good massage is certainly familiar with the seemingly magical way that a therapist can find the perfect spots and “good pain.” An inability to reliably find something does not mean it can’t be done. And the main reason no treatment has ever been proven effective is mostly a lack of good science on the subject — it’s just unknown.
Countless known and unknown factors influence the outcome of any massage — far too many. The result is a weird mix of genuine potential with therapeutic unpredictability and mediocrity.
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Massage is a profoundly valuable service regardless of what specific effects it does or does not have on pain, tissues, or pathologies. A pleasant, relaxing experience may have any number of minor therapeutic benefits, such as bringing your blood pressure down. However, the subtler benefits of massage likely extend well beyond that, into the territory of emotional and psychological benefits that are virtually impossible to define or measure.
It may reduce suffering in these ways, even if it doesn’t reduce pain itself.
Recently, after a long interval without massage, I got a brief chair treatment. Such relief! It was dazzling and unforgettable, like being struck by friendly lightning. After 26 years of study, I still don’t know why massage is such an intense sensory experience — only that it is, and that it clearly matters to people.
I don’t think anyone disputes that “touch is profound” for primates. We know it’s biologically vital for baby mammals, who seem to need it to grow and thrive.9495 We can extrapolate from those mechanistic foundations to a safe assumption that it’s psychologically profound for adults too. Anything that important to our literal growth probably has emotional weight for our entire lives. Which is likely why massage does in fact attenuate anxiety and depression (substantiated earlier). Which is probably not an isolated effect — just the most measurable outcome of a complex network of effects, the tip of an iceberg of psychological value.
It would be silly for me to claim that I know what “psychologically profound” actually means (in reference to anything, not just massage). But I do think that a lot of fresh, novel sensory stimulation can quite literally raise self-awareness. Receiving massage is kind of like a guided meditation that brings your attention not only to many specific parts of your body. Noticing that you feel vulnerable here but robust and comfortable there can be subjectively valuable information, new self knowledge.
Any massage therapist who has been working for more than a month has observed the curious way that touch provokes introspection, insight, and inspiration. The revelations of contact — “I had no idea I felt this way!” — transmogrifydefine“To change or alter greatly.” From the Calvin & Hobbes comic strip. into revelations with broader significance. Intense and novel sensations can be a catalyst for personal growth. Above all, massage reminds us what it feels like to feel good … a reminder we often badly need. We may then feel highly motivated to reclaim that sense of well-being in the rest of our lives.
Whether it is the actual goal of therapy, or just an intriguing side effect, the sensations of massage can change our ideas about ourselves, how it feels to be in our own skin, and maybe bump us out of some other sensory rut96 — and that, in turn, may give us some leverage on our emotional ruts. The rich sensory experience has complex effects on emotions and cognition.
And personal growth and emotional maturation probably have some clinical relevance to recovery, healing, and vulnerability to chronic pain. See Pain Relief from Personal Growth and Vulnerability to Chronic Pain.
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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 — confession! — 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. After all, if patients were my experimental research subjects, shouldn’t I have been paying them?
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 among common 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.
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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. They don’t just pay lip service to humility as a general principle of alternative medicine — they make it a centerpiece, recognizing that they really are not trained enough to know much. And they actually continue their academic education — which is far more important than the skills, methods, techniques that actually dominates most continuing "education" for massage therapists. They read and they study. They give a damn about the science.
Meanwhile, bad massage therapists oversell a narrow selection of less effective and mostly faith-based options, and generally lack the training or critical thinking skills to recognize their own limitations. This is no different in principle than any other health care profession.
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About Paul Ingraham
I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:
- Reassurance for Massage Therapists — How ethical, progressive, science-respecting massage therapists can thrive in a profession badly polluted with nonsense
- How Do Your Find Good Quality Massage Therapy? — Tips for finding good quality medical massage, and avoiding nonsense and quackery
- Basic Self-Massage Tips for Myofascial Trigger Points — Learn how to massage your own trigger points (muscle knots)
- Poisoned by Massage — Rather than being DE-toxifying, deep tissue massage may actually cause a toxic situation
- Palpatory Pareidolia & Diagnosis by Touch — Tactile illusions, wishful thinking, and the belief in advanced diagnostic palpation skills in massage and other touchy health care
- Why Drink Water After Massage? — No reason! Massage therapy does not flush toxins into the bloodstream, and water wouldn’t help if it did
Around the internet…
- “Why I Quit My Massage Therapy Career,” Paul Ingraham, Sciencebasedmedicine.org. In 2007, I was accused by my profession’s regulator of being an ‘unprofessional’ Registered Massage Therapist for criticizing pseudoscience in alternative medicine. I accepted an unusual public reprimand and made a few changes to my website, but my regulator pressed their case, effectively demanding that I quit writing altogether. I quit the profession instead.
- “Evidence-based massage therapy: a contradiction in terms?,” Ernst, Massage Therapy: The Evidence for Practice, 2002.
- “The masseuse who pulled my arm out,” Angela Clarke, BBC.
- “Enough is Enough,” Jason Silvernail, SomaSimple.com.
- A couple items from Alice Sanvito, LMT:
- How Does Massage Work? on mechanisms of massage, highlighting the extraordinary sensory richness of skin and the surprising blind spot that massage therapists have for the neurological, tactile mechanisms of massage.
- Death and Rebirth as a Massage Therapist, on getting comfortable with science and uncertainty in massage therapy.
- 5 Myths and Truths about Massage Therapy: Letting Go without Losing Heart [PDF, 50 pages], an fine short ebook written in the same spirit as this article, but offering plenty of other ideas and perspectives.
- “Massage Therapy: Riddled with quackery,” Stephen Barrett, QuackWatch.org.
- “Does massage therapy decrease inflammation and stimulate mitochondrial growth? An intriguing study oversold,” David Gorski, ScienceBasedMedicine.org.
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The explanation for the title of this section comes right at the end of the quoted passage below. It’s a funny payoff — hang in there for it!
Many times over the years I’ve been told by more rational massage therapists that I’m overstating how much massage therapy is polluted with quackery. I wish I could agree. There are many reasons why massage therapists get this wrong.97
I think the true situation in most areas of the world is realistically described by this passage from Laura Allen’s excellent book, Excuse Me, Exactly How Does That Work? Hocus pocus in holistic healthcare She reports a dizzying litany of nonsense attached to “massage therapy.” Note that hardly a stitch of it has the slightest thing to do with actual massage (hell, not even myths about massage). And note that she is describing the sort of things she used to buy into (literally). Laura Allen is a self-described reformed flake.
We took turns lying down on the classroom tables, closing our eyes, and running our hands over the bodies of our supine partners and then experiencing them doing the same to us. Whatever we felt was referred to as “energy.” We were taught a few techniques for “clearing negative energy” and “balancing the chakras” by “removing the congestion” that exists in the energy field.
These involved a lot of muscle testing, and I’m not talking about orthopedic assessments. I’m talking about asking your arms (that was the terminology) if you should eat this or that food, or hire this or that lawyer, or marry this or that person. My husband and I both ended up taking the advanced program in that, which was 120 hours of learning to read people’s faces and body language, and giving and receiving a lot of what was referred to as “emotional stress diffusions.”
We also went on to do Reiki II, which was optional. That was where we learned how to do distance healing. Yes, I actually believed that you could be in Alaska, and that I could be sitting in my North Carolina home sending you a healing.
The owner of the school collected (and sold) crystals, and used them for healing purposes. I ended up amassing quite a collection of my own, using them to do chakra balances on people, performing psychic surgery with them, and any number of woo procedures. I also purchased magnetic pads for my massage table. I attended homeopathy workshops. I got heavily into essential oils, which I still love and use today—with the caveat that while I think many of them are useful as folk remedies for various simple ailments, I’m not going to advise someone with cancer that they can cure it with an oil, which unbelievably, I notice massage therapists doing all the time—and worse—on social media.
I stayed there as the administrator and an instructor for five years after I graduated, and during that period of time, I could not possibly even name all the things I went through. I had a lot of psychic readings. I availed myself of EFT (Emotional Freedom Technique), an invention of Dr. Mercola, [sic]98 which basically consists of tapping on meridian points in order to relieve emotional negativity, food cravings, and pain. I tried Aura Soma, which is described as “color healing.” I got tuned up with tuning forks, and crystal bowls. I participated in one workshop called Matterspeak, which consisted of sitting around chanting random words, letters, and numbers for 8 hours, as in “1263supercalifragilisti789.” I don’t remember what the purpose of that was and frankly doubt that it had any purpose, other than to enrich the teacher’s pocketbook. If memory serves, she had “channeled” that information from the Atlanteans. I also used the chi machines, the detox foot baths and pads, biofeedback and all kinds of computer programs designed to balance your body, mind and spirit, and most New Agey-sounding things in existence at the time. If it was out there, I tried it. All kinds of “healers” came and went through the school.
While we were on a road trip out west, I collected some buffalo dung—I actually witnessed the buffalo relieving himself, waited until he ambled off, and I jumped out of the car with a zip-lock bag to harvest it for future ceremonial purposes.
Since it had come from a buffalo on the reservation I figured it was more powerful than your average cow dung.
It was, indeed, powerful bullshit!
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In 2012, the Facebook page Anatomy in Motion published this infographic, which quickly went a bit viral with hundreds of likes and shares, as infographics do.
AiM is popular with massage therapists, and the comments on the post were overwhelmingly positive, reflecting the strong tendency in the massage therapy community to uncritically embrace anything sciencey that makes massage sound good. Typical examples (with typical grammar and spelling) reflect rather poorly on the profession:
- Keicher Payne wrote, “Stealing and sharing and going to shout it from the rooftops!”
- Norma Leos: “Ohh, thank you very much, Im a massage therapist too...Im going to share!! Thank you!”
- Caterina Caravello: “Massage is a necessity for a crossfit athlete. Performance enhancement :)”
- Christine Reid: “Ty so much for posting this !!! I tried telling my clients for 3 years this !!!!!!!!!!! I LUV IT!!”
Unsurprisingly, there are almost no comments questioning or challenging anything about the image. Julie Onofrio chimed in with one of the only genuine criticisms: “a few of the things on there are not correct — massage has not been proven to increase endorphins or decrease cortisol.” Agreed: most of the infographer features common scientific myths about massage.
Another commenter complains that the infographic makes massage sound too much like an “indulgence” and not enough like “health care.” It’s clear that he wants to make grander claims for massage, regardless of the evidence. Irony fail! If there was stronger evidence to cherry-pick in service of promoting massage as medicine, it would have ended up on this infographic.
Certainly the infographic is a bit exaggerated. It could be a lot worse — hey, at least it’s got references! But it could be a lot better. Citing single cherry-picked studies to support broad treatment claims is weak sauce, even if the picks are good (and clearly not all of these are). The evidence and claims here that are stronger are also less important … and those that are more clinically important are also less sound.
Here’s an example of strong-but-unimportant: it’s highly plausible and fairly confirmed that massage is relaxing (shocker), but paying $1+/min for relaxation alone would be luxury wellness care, not “medicine.” Of course relaxation is a good thing and has some value, but it’s disingenuous to pitch it as “health care.”
The constipation claim is another good example of something that’s probably as clinically trivial as it is certain. Who the hell thinks, “I haven’t had a crap in days: I guess I’d better buy a professional massage!” (I might rub my own belly.) In ten years working as an RMT, I think I did that kind of abdominal massage maybe a half dozen times — demand for the service was rather low. I’ve been writing about the science of massage even longer, and this is literally the first time the word “constipation” has ever appeared on this website — because who cares?
Flipping it the other way, the infographic features a particularly obvious example of an important-but-weakly-supported claim: boosting “athletic performance.”
No question: actually boosting performance would be a big deal, a humungous deal! But the cited evidence doesn’t remotely substantiate such a mighty claim. Even if we take that evidence at face value, it’s a huge and oversimplified reach to conclude that “a little increased range of motion” constitutes a meaningful effect on athletic performance as a whole. I can increase my ROM with a few seconds of stretching, too … and stretching does not enhance performance (look it up).
Now, think back to Caterina Caravello’s comment above, asserting that massage is a “necessity” for athletic performance. What would all the athletes who win medals without massage make of that?
So obviously (duh) this infographic was designed to score medical credibility points for massage, and research was cherry-picked to support that goal, and there wasn’t any chance that any discouraging words or science was going to make the cut! But it something like this will get applause from almost everyone who sees it, because people love to love massage, because massage is a lovely experience for all kinds of reasons.
But whether or not massage is good medicine is still an open question, and this infographic is really just a bit of mild-mannered propaganda. Amatereurish boosterism never does a profession any favours. Paying lip service to science for promotional purposes cheapens it and impedes progress and understanding. Enthusiastically approving of such poor-quality information is a disturbing sign of how far the profession of massage therapy still has to go before it can be taken seriously as a full partner in health care.
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This article thoroughly discusses massage therapy in a way that is quite unusual in the profession: a skeptical, critical-thinking sort of way. This is normal in modern medicine, where critical self-appraisal is a formal part of the professional culture.99 And yet there are some skeptical massage therapists! We do exist! For instance, the Skeptical Massage Therapists Facebook group has quickly grown into the best discussion group available — although there’s not much competition! — for massage therapists who also happen to be scientific skeptics. Founder and moderator Brantley Moate:
To be a member, you need to be a massage therapist and you actually know you’re a scientific skeptic. It’s not a place for massage therapists to find out what scientific skepticism is.
Scientific skeptics are the kind of people who would go to an amazing meeting, or less-amazing nights with some other skeptics in the pub. We are used to being misunderstood. Almost no one really knows what scientific skepticism is all about.
I doubt that I personally know any skeptical massage therapists who aren’t already there, if they want to be, but I may have readers who qualify. Such skeptics are obviously a rarity in massage therapy, a profession notorious for attracting people with New Age and fringe science beliefs. The kind of people who would happily pay through the nose for tickets to see Deepak Chopra talk and think Mercola.com is a good source of health care information.
Modern social media excels at bringing together special interest groups with low-density populations. This is one of the best examples I can think of.
This is one of the oldest articles on PainScience.com, with bits and pieces of it dating back to the late 90s (though all edited and revised at some point).
2022 — New section: Well, this is rather overdue. [Updated section: Foam rolling (is just massage).]
2022 — Minor addition: Added “nostril yanking therapy” as an example of pseudoscience in massage. [Updated section: Massage Science and Mythology.]
2021 — Science update: Added the particularly interesting example of autonomous sensory meridian response to the discussion of the power of touch. [Updated section: The best scientific case for massage therapy possible to date.]
2021 — Edited: Proofreading and minor editorial polish.
2021 — Added a myth: Added an old massage myth I should have added long ago: the idea that rubbing certain acupuncture points can induce labour. It really can’t. Just not a thing. [Updated section: The many myths of massage therapy.]
2020 — Added information: Compared and contrasted the practice of massage in other “manual therapy” professions like chiropractic, osteopathy, and physiotherapy. [Updated section: Types of massage therapists.]
2020 — Upgraded: Significantly expanded on the discussion of how massage might have profound psychological significance to people. [Updated section: Raising awareness and stimulating personal growth: the best thing about massage.]
2020 — Minor addition: Added an infographic of massage benefits as a negative example of typical claims about the profession. [Updated section: Massage Science and Mythology.]
Archived updates — All updates, including 16 older updates, are listed on another page. ❐
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I was a Registered Massage Therapist with a busy practice in downtown Vancouver from 2000–2010. Since then, I have made my living writing about musculoskeletal medicine and pain science, with a reputation for a skeptical perspective. And I make a large portion of my income from an e-book about a specific type of massage (trigger point therapy).
So I have competing, complicated biases. I do my best to compensate for them by sticking to what the evidence can support, and clearly identifying speculation and experimental therapy for what it is.
This is exactly the right idea and the right spirit, which is not expressed nearly often enough, or firmly enough:
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, Utah
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.
- Ingraham. 💩 Massage Therapists Say: A compilation of more than 50 examples of the bizarre nonsense spoken by massage therapists with delusions of medical knowledge. ❐ PainScience.com. 11683 words.
- Osteopathy is a confusing profession with colourful history, extremely diverse training and certification standards, and not much to unite practitioners except their focus on musculoskeletal health. Some osteopaths have true medical degrees, but that’s mostly in the United States and England. Most are lesser-trained alternative medicine practitoners, indistinguishable from chiropractors as far as most patients are concerned. For more information, see Reviews of Pain Professions.
- Mealy K, Brennan H, GCC F. Early Mobilization of Acute Whiplash Injuries. BMJ. 1986;292:656–7. PubMed 3081211 ❐
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 ....”
- McKinney LA. Early mobilization and outcome in acute sprains of the neck. BMJ. 1989 Oct;299(6706):1006–8. PubMed 2511939 ❐ PainSci Bibliography 56881 ❐
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.”
- Pichonnaz C, Bassin JP, Lécureux E, et al. The effect of manual lymphatic drainage following total knee arthroplasty: a randomized controlled trial. Arch Phys Med Rehabil. 2016 Jan. PubMed 26829760 ❐
This is a test of manual lymphatic drainage (MLD), a gentle massage-like technique that allegedly reduces swelling by stimulating the natural mechanisms that drain excess fluids from between cells. Testing MLD is fairly easy and interesting, because it’s supposed to have such an objective, measurable effect.
So how did five doses of MLD work on 30 patients who’d just had knee surgery (total knee arthroplasty)? Compared to 30 others who got a placebo.
It didn’t work! No difference. MLD bombed this straightforward test. Alas.
It did reduce pain quite a bit right in the early stages, which is a nice demonstration of something we already know — gentle touch is quite soothing — but does little itself to justify MLD as a modality.
A bit of good news: knee passive flexion contracture was a little reduced in the MLD group after 3 months. That’s a nice result, but a modest one, and not pertinent to the central claim of MLD.
Some procedural notes: swelling was measured all fancy-like, “using bioimpedance spectroscopy and volume.” All patients “followed the standard rehabilitation program of the department,” including ice, passive motion, strengthening, and getting walking. And the MLD treatments were done by therapists we have every reason to have confidence in: “five physiotherapists with experience in MLD who completed two training sessions for standardization. The same therapist performed all of the study treatments for a given patient. The treatment was standardized according to the recommendations of Földi and Kubik.”
- Ezzo J, Manheimer E, McNeely ML, et al. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Syst Rev. 2015;5:CD003475. PubMed 25994425 ❐
This 2015 review of six studies of manual lymphatic drainage for breast cancer-related lymphedema is about as on-point as we can hope for if we want to know if MLD works. BCRL is the indication for which MLD is best known. Note that swelling reduction is by far the most important outcome measure.
And it’s a tepid mix. The conclusions aren’t wholly negative, but they are way less positive than they should be. There is some promising evidence here that suggests MLD probably helps some of these patients at least a little bit some of the time, but even that “needs to be confirmed.” And a couple studies showed some modest swelling reduction — but really not that much, or not even a statistically significant result.
But mostly the evidence is a classic example of damning with faint praise. There’s definitely a failure of MLD to demonstrate the kind of clear reductions in swelling we would like to see based on its reputation.
- 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).
“Tendinitis” versus “tendonitis”: Both spellings are acceptable these days, but the first is the more legitimate, while the second is just an old misspelling that has become acceptable only through popular use, which is a thing that happens in English. The word is based on the Latin “tendo” which has a genitive singular form of tendinis, and a combining form that is therefore tendin. (Source: Stedmans Electronic Medical Dictionary.)
“Tendinitis” vs “tendinopathy”: Both are acceptable labels for ticked off tendons. Tendinopathy (and tendinosis) are often used to avoid the implication of inflammation that is baked into the term tendinitis, because the condition involves no signs of gross, acute inflammation. However, recent research has shown that inflammation is actually there, it’s just not obvious. So tendinitis remains a fair label, and much more familiar to patients to boot.
- 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 may be the first ever scientific test of friction massage for tendinitis. In 1989 (when I was graduating from high school!), “No clinical trials, either controlled or uncontrolled, reporting the effectiveness of friction massage could be found.” From the conclusion: “This study does not support the notion that either deep friction massage or phonophoresis are superior to ultrasound in the treatment of lateral epicondylitis at the elbow.”
- There are plenty of sketchy treatments in physical therapy, too, especially ultrasound.
- Rosa L, Rosa E, Sarner L, Barrett S. A close look at therapeutic touch. JAMA. 1998 Apr 1;279(13):1005–10. PubMed 9533499 ❐ PainSci Bibliography 56856 ❐
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. Emily Rosa’s experiment showed 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, let alone manipulating it therapeutically. The test made them look ridiculous.
Ms. Rosa was just nine years old when she did this experiment, and remains the youngest person to have a research paper published in a peer reviewed medical journal. (It is, of course, likely that she had some parental assistance — but I don’t know the whole story.)
- Many students at my school were actually angry that things like therapeutic touch were even being taught. I recall some heated debates between skeptical students and more “open-minded” instructors and school officials. It may surprise you to hear that I was not one of the skeptics back in those days — it was only just starting for me then.
- Hartman SE. Cranial osteopathy: its fate seems clear. Chiropractic & Manual Therapies. 2006;14:10. PainSci Bibliography 56267 ❐
A short but clear, compelling, and strong critique of cranial osteopathy. As an osteopath himself, Dr. Hartman’s opinion carries considerable weight, and he writes well. He concludes that techniques based on the assumptions of cranial osteopathy “should be dropped from all academic curricula; insurance companies should stop paying for them; and patients should invest their time, money, and health elsewhere.”
- Not all quackery is obvious — not even to skeptics. It often masquerades as mainstream or technological treatment, and is superficially plausible. Pseudo-quackery is rampant in physical therapy. Because it hides right in the mainstream, it does much more harm than more overt quackery, which is marginalized and relatively rare. For more information, see Pseudo-Quackery in Physical Therapy: The large, dangerous grey zone between evidence-based care and overt quackery in treatment for spain and injury.
- Ingraham. A Historical Perspective On Aches ‘n’ Pains: We are living in a golden age of pain science and musculoskeletal medicine … sorta. ❐ PainScience.com. 3066 words.
This is from an interview of Jim Asher in The “Journal” of the Rolf Institute (December 2012), talking about Ida Rolf’s mentorship on the subject of nasal/cranial work:
DG: You mentioned that in her nose work, she didn’t go all the way in. Did she talk about going into the three conchae?
JA: Yes. She’d say there are three conchae in there, and that the goal is to get them open. She’d say, “You do what you can do.” Sometimes she would just get into the bottom one, which is the largest. She’d have you look at your anatomy book, and she wanted you to visualize those three conchae opening. Ida was a big believer in visualization. You visualized what’s underneath the skin and the connections [while you were working on it]. When you’re doing the sacrum, you’re visualizing the dural tube and all the way up, feeling up through the body.
DG: Did she ever mention any esoteric reasons for doing the nose work, like doing a Rolfing session on the brain or opening the third eye, or anything like that?
JA: Yes. She would have you visualize the pituitary gland, say “You’re affecting the pituitary gland.” She was especially interested in the pituitary. Sometimes she would talk about the third ventricle as well.
And that’s the tip of the nonsense iceberg. I wish I could say it was just colourful 1970s silliness, but this is still an embarrassingly common kind of pseudoscience in massage therapy to this day.
- Tests of overall effectiveness (clinical trials) are not difficult to cook up in principle: just take a hundred people with a certain kind of problem, give some kind of reasonably appropriate massage to fifty of them, give a neutral treatment to the other fifty, record the results, and report them. It’s not perfect, but it doesn’t have to be perfect to detect what should be a reasonably strong effect — if those massaged 50 people aren’t better off, how good can massage be? A great deal more precision is required to answer exactly what kind of massage works how well for what — more on that in a moment — but in broad strokes, it’s not a difficult problem. Not in principle.
It 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 effective where another combination fails? How well trained is the therapist? Are “advanced” techniques better than relaxation and Swedish techniques? Or maybe the basics are the basics because they really work? How much massage therapy? Could five sessions succeed where two would fail? Is one appointment “massage therapy,” or does it really need more? Could nine 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.
- Technically, it’s a failure to do an analysis of variance (ANOVA). This is actually strongly relevant to massage research. For a surprisingly interesting detailed explanation, with comic strips and funny videos, see Statistical Significance Abuse.
- Hall H. Vision of Specialization for Registered Massage Therapists. massagetherapy.bc.ca. 2009. PainSci Bibliography 55648 ❐
I’ve often said that massage therapy research is in its early stages. And after thinking about that more today, I’ve realized it’s worse than that. Massage therapy research is stunted, and not showing signs that it is ready to progress. Some might disagree, and would point to the increasing number of massage therapy studies. (I’ve charted it myself in at least one paper I’ve published, and there is no doubt that the number of papers on the subject is increasing.) But I would counter by noting that there is no discussion in the field. The studies are conducted and published in isolation. They are not often being critiqued, and researchers with different theories and perspectives are not addressing each other in the literature or even at conferences.
Dr. Christopher Moyer, Facebook post
- Webb TR, Rajendran D. Myofascial techniques: What are their effects on joint range of motion and pain? A systematic review and meta-analysis of randomised controlled trials. J Bodyw Mov Ther. 2016 Jul;20(3):682–99. PubMed 27634094 ❐
A review of nine studies of dubious quality of “myofascial technique” — rubbing and stretching basically — for joint pain and stiffness. Although all the studies showed improved range of motion and reduced pain, most clearly for the jaw, the authors of this review think that there are “a number of threats that challenge the statistical inferences underpinning these findings.” Translation: they think the studies they reviewed are of poor quality and that their conclusions cannot be trusted (garbage in, garbage out). Obviously the science is incomplete, but there are some reasons for optimism here (and it’s not exactly a huge claim that some rubbing and stretching might help a painful, stiff joint).
- Nolano M, Provitera V, Crisci C, et al. Quantification of myelinated endings and mechanoreceptors in human digital skin. Ann Neurol. 2003 Aug;54(2):197–205. PubMed 12891672 ❐
This geeky basic neurology experiment produced a rough estimate of the density of nerve endings in human glabrous (hairless) skin: about 6000 per square centimetre, so a whole hand probably contains about as many as the maximum capacity of the largest stadiums in the world. They measured an average nerve diametre of about 3 thousandths of a millimetre.
- Loken LS, Wessberg J, Morrison I, McGlone F, Olausson H. Coding of pleasant touch by unmyelinated afferents in humans. Nature Neuroscience. 2009 May;12(5):547–548. PubMed 19363489 ❐ PainSci Bibliography 55426 ❐
Nerve impulses that tell the brain that we are being slowly stroked have their own specialised nerve fibres in skin. This discovery may explain why touching the skin can relieve pain, and that is obviously important to touch therapies. It strongly implies that neurological responses to touch have considerable complexity.
- Poerio GL, Blakey E, Hostler TJ, Veltri T. More than a feeling: Autonomous sensory meridian response (ASMR) is characterized by reliable changes in affect and physiology. PLoS One. 2018;13(6):e0196645. PubMed 29924796 ❐ PainSci Bibliography 52152 ❐
I go into more detail about this in Autonomous Sensory Meridian Response: That nice, weird tingly head feeling (and its possible relevance to healthcare and treating pain, especially with massage).
- Massage-StLouis.com [Internet]. Sanvito A. How Does Massage Work?; 2016 December 31 [cited 17 Feb 28]. PainSci Bibliography 53743 ❐ While the skin is indeed “the surface of the brain,” there are of course many sensory receptors in deep tissues as well. Massage therapy mainly interacts with the nervous system via the skin, which is extremely richly innervated, and the importance of this is often underestimated or discounted entirely … but it’s not limited to that. For instance, I’ve always particularly loved having my joints moved passively, which creates a flood of proprioception — movement/position sensation — that my brain didn’t initiate, which feels weird in a delicious way.
- Counterstimulation is a well-documented, albeit minor mechanism for touch-induced analgesia. Basically, tactile sensation often partially, transiently pre-empts pain. But the right sensory inputs — mostly just especially nice ones — can probably mediate a beefier analgesic effect. I explore that hypothesis in Counterstimulation, Counterirritation, and Gate Control: Minor but reliable, counterstimulation is the most basic pain-killing mechanisms in biology… and maybe there’s a fancier version that’s more useful.
- We cannot trust our eyes, or our pain. Pain is a lot like these amazing illusions — that is, it is warped by our expectations and point of view (see Pain is Weird). Unlike these clever models, though, we can’t turn it around to see what’s really going on. And trying to see through the illusion, trying to believe that there’s nothing much actually wrong with our tissues (often true), is even more difficult than seeing through these illusions. But that challenge is what recovery is all about: trying to change our expectations and point of view with interesting new sensations and movements. Massage therapy may be one of the very best sources of the sensory data needed to change our perspective.
- Farinatti PTV, Brandão C, Soares PPS, Duarte AFA. Acute effects of stretching exercise on the heart rate variability in subjects with low flexibility levels. J Strength Cond Res. 2011 Jun;25(6):1579–85. PubMed 21386722 ❐
This study of stretching found that
multiple-set flexibility training sessions enhanced the vagal modulation and sympathovagal balance [that’s good] in the acute postexercise recovery, at least in subjects with low flexibility levels. … stretching routines may contribute to a favorable autonomic activity change in untrained subjects.
This seems like a fairly straightforward bit of good-news science about stretching. It’s not a surprising idea that movement would have some systemic regulatory effects (motion is lotion, use it or lose it), but it’s nice to see some corroboration of that common sensical notion, and it’s also nice to know that perhaps just stretching did this (to the extent we can learn anything from a single study). If true, it makes for nice evidence to support a general stretching habit, yoga, mobilizations, really any kind of “massaging with movement,” and probably even massage itself.
- Complete lists of studies published by the Touch Research Institute.
- The Touch Research Institute has conducted dozens of small studies showing the positive effects of massage and touch therapies on many conditions. It’s all a little too good to be true (or all true). I think the Touch Research Institute designs studies in such a way that a positive spin on touch therapy is inevitable. For instance, many of their papers are particularly afflicted by two statistical errors: confusing statistical and clinical significance (or just ignoring the difference when convenient), and comparing the wrong things to arrive at so-called “significance” (see Statistical Significance Abuse: A lot of research makes scientific evidence seem much more “significant” than it is.) 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.” Satisfaction is not a meaningful outcome. People are often satisfied with snake oil — that doesn’t mean it works! Some of these scientific papers seem more like press releases, produced by a professional association to promote the profession of massage therapy. I no longer take TRI studies seriously.
- Field T, Reif HM, et al. Juvenile rheumatoid arthritis: Benefits from massage therapy. Journal of Pediatric Psychology. 1997;22:607–617.
- 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. PubMed 11315685 ❐
- Field T, et al. Autistic children’s attentiveness and responsivity improved after touch therapy. Journal of Autism & Developmental Disorders. 1986;27:329–334. PubMed 9229263 ❐
- Kutner JS, Smith MC, Corbin L, et al. Massage Therapy versus Simple Touch to Improve Pain and Mood in Patients with Advanced Cancer: A Randomized Trial. Ann Intern Med. 2008 Sep 16;149(6):369–379. PubMed 18794556 ❐ PainSci Bibliography 56107 ❐
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 … but they both helped. 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 can. 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. (Over the years, I’ve seen many amateurs who could give excellent massages simply by virtue of their empathy and attentiveness. Could massage “skill” be mostly just an extension of social skills? Might be.)
Incomplete blinding is a significant weakness in the study. The massage therapists knew what treatment they were giving: “possibly leading to reporting bias and the overestimation of a beneficial effect.”
- Jane SW, Chen SL, Wilkie DJ, et al. Effects of massage on pain, mood status, relaxation, and sleep in Taiwanese patients with metastatic bone pain: A randomized clinical trial. Pain. 2011 Oct;152(10):2432–42. PubMed 21802850 ❐
- Moyer CA. Affective massage therapy. Int J Ther Massage Bodywork. 2008;1(2):3–5. PubMed 21589715 ❐ PainSci Bibliography 54758 ❐
Two general effects [of massage, MT] are well-supported by scientific data and widely agreed-upon by MT researchers. Quantitative research reviews show that a series of MT treatments consistently produces sizable reductions of depression in adult recipients. The effects of MT on anxiety are even better understood. Single sessions of MT significantly reduce state anxiety, the momentary emotional experiences of apprehension, tension, and worry in both adults and in children, and multiple sessions of MT, performed over a period of days or weeks, significantly reduce trait anxiety, the normally stable individual tendency to experience anxiety states, to an impressive degree in adults.
Together, these effects on anxiety and depression are the most well-established effects in the MT research literature. They are especially important for us to understand not only for their own sake, but also because anxiety and depression exacerbate many other specific health problems. In other words, it is reasonable to theorize that quite a few specific health benefits associated with MT may actually be “second-order” effects that are a consequence of MT’s “first-order” effects on anxiety and depression.
- Shulman KR, Jones GE. The effectiveness of massage therapy intervention on reducing anxiety in the work place. Journal of Applied Behavioral Science. 1996;32:160–173.
- Cady SH, Jones GE. Massage therapy as a work place intervention for reduction of stress. Perceptual & Motor Skills. 1997;84:157–158. PubMed 9132704 ❐
This 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.
- Hernandez-Reif M, Field T, et al. High blood pressure and associated symptoms were reduced by massage therapy. Journal of Bodywork & Movement Therapies. 1999;4:31–38.
From the abstract: “Massage therapy may be effective in reducing diastolic blood pressure and symptoms associated with hypertension.”
- 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. PubMed 9656043 ❐
The no-brainer conclusion: “Back massage is useful for promoting sleep in critically ill older men.” Most likely that sentence could stop at “promoting sleep” and it would still be correct, but I understand the need for precision.
- Furlan AD, Imamura M, Dryden T, Irvin E. Massage for low-back pain. Cochrane Database Syst Rev. 2008;(4):CD001929. PubMed 18843627 ❐ PainSci Bibliography 55772 ❐
- Furlan AD, Giraldo M, Baskwill A, Irvin E, Imamura M. Massage for low-back pain. Cochrane Database Syst Rev. 2015 Sep;9:CD001929. PubMed 26329399 ❐
- Dr. Christopher Moyer explains the flip-flop in an interview for Massage & Fitness Magazine:
I think it is more that they are circumspect than pessimistic. Speaking as a scientist, we are very careful to guard against declaring a finding if there is even a small risk of it being a false positive. We never want to say ‘we’ve found something’ and later have it turn out we were wrong when more data comes in. So, I think they are hewing to scientific norms in this regard, and I do not fault them for that; it is important to be careful in science.
In this case, they may have regretted saying “massage is beneficial” based on inadequate evidence in the past, because they did indeed have to walk their optimism back as more data came in. But was it because the results were less positive? Or just that the evidence is such junk?
- Preyde M. Effectiveness of massage therapy for subacute low-back pain. Canadian Medical Association Journal. 2000 Jun 27;162(13):1815–20. PubMed 10906914 ❐ PainSci Bibliography 56883 ❐
- Ontario has one of the world’s best education and certification programs for massage therapy.
- Oppel L. Is massage therapy genuinely effective? CMAJ. 2000 Oct;163(8):953; author reply 953–4. PubMed 11068563 ❐ PainSci Bibliography 52962 ❐ Incidentally, Dr. Oppel is an acquaintance of mine, and — more importantly — a super sharp guy with a lot of experience with critical analysis. I place a lot of faith in his judgement. If Lloyd says Preyde’s experiment is critically flawed and actually tells us massage does not work, I am inclined to agree. And inclined to be sad about it.
- Cherkin DC, Sherman KJ, Kahn J, et al. A comparison of the effects of 2 types of massage and usual care on chronic low back pain: a randomized, controlled trial. Ann Intern Med. 2011 Jul;155(1):1–9. PubMed 21727288 ❐ PainSci Bibliography 55286 ❐ For detailed analysis, see Massage Therapy Kinda, Sorta Works for Back Pain.
“Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months”: A strongly positive summary, barely tempered by the word “may.” Unfortunately, their evidence does not really support such a sunny conclusion. In fact, their data showed that the benefits of massage were minor to begin with, and barely detectable after six months. Worse still, there’s that lack of blinding thing again. They concede the flaw but fail to acknowledge its serious implicates: if anything, as with Michele Preyde’s study, it flips the story, from good news to a depressing evidence of absence.
Never in a million years would I have summarized the way they did. I would have said, “A lot of expensive massage produced minor, temporary benefits at best, and maybe none at all.” That seems like a much more intellectually honest description!
- Deyo RA, Ciol MA, Cherkin DC, Loeser JD, Bigos SJ. Lumbar spinal fusion: a cohort study of complications, reoperations, and resource use in the Medicare population. Spine. 1993;18:1463–70. That’s what he thought in 1993, anyway.
- Wall P. Pain: the science of suffering. Weidenfeld and Nicholson; 2000.
- QuackWatch.org [Internet]. Barrett S. Massage Therapy: Riddled with quackery; 2006 [cited 13 Apr 5]. PainSci Bibliography 56500 ❐
Scientifically unsupportable ideas are common among massage therapists, according to Dr. Stephen Barrett. He avoids a blanket condemnation of the profession, conceding that “ordinary massage and the legitimate practice of massage therapy should not be categorized as quackery.” However, “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.” He provides many references to support this 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 neglect some nice things that can be said about massage therapy, and it contains a few minor errors. 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.
- Li YH, Wang FY, Feng CQ, Yang XF, Sun YH. Massage therapy for fibromyalgia: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9(2):e89304. PubMed 24586677 ❐ PainSci Bibliography 53919 ❐
- Cambron JA, Dexheimer J, Coe P, Swenson R. Side-effects of massage therapy: a cross-sectional study of 100 clients. J Altern Complement Med. 2007 Oct;13(8):793–6. PubMed 17983334 ❐
10% of 100 patients receiving massage therapy reported “some minor discomfort” in the day following treatment. 23% reported unexpected, non-musculoskeletal benefits. Interestingly, that means that most of these patients experienced no noteworthy effect at all, good or bad.
This study did not include enough people to rule out the possibility of rare and/or serious side effects of massage therapy.
For contrast, a more general study of all kinds of manual therapy (see Carnes), including massage, found that 20-40% of treatments will cause some kind of unpleasantness, side effect, or “adverse event” in medicalspeak.
- Mori S, Ai T, Otomo Y. Laceration of the transverse mesocolon in an old man with a habit of abdominal massage for constipation: a case report. Surg Case Rep. 2020 Jan;6(1):1. PubMed 31898753 ❐ PainSci Bibliography 52515 ❐
This is a description of a case of intestinal injury following self-massage of the abdomen intended to help constipation. A 68-year-old man with chronic constipation had a habit of abdominal self-massage, and “did it hard” shortly before developing severe belly pain. He was misdiagnosed with a tumour at the hospital. A day later, still bleeding internally, a surgeon found a litre and a half of blood and a five centimetre tear in his upper colon. The patient recovered surprisingly well after an imperfect repair — the intestinal tissue was too fragile to stitch the tear closed properly. His only complication was an ironic increase in constipation from a paralyzed intestine. When traumatized, the intestine stops contracting for safety.
The authors of the report reasonably assume that the injury was caused by the self-massage, but note other possible explanations, “such as rupture of small aneurysms.” However, the lesion was quite a bit too large to be explained by anything but the most obvious.
- Straightforward palpatory pareidolia. Pareidolia is a type of illusion or broken perception in which a vague or obscure stimulus — i.e. subtle textures under your skin — is perceived as if it was clear and distinct. Pareidolia is what makes naive Christians spot Jesus in a T-shirt stain, and why Percival Lowell thought he could see canals on Mars.
- Maigne JY, Cornelis P, Chatellier G. Lower back pain and neck pain: is it possible to identify the painful side by palpation only? Ann Phys Rehabil Med. 2012 Mar;55(2):103–11. PubMed 22341057 ❐ PainSci Bibliography 54321 ❐
Researchers tested two physicians with training in manual medicine to see if they could detect the painful side of the neck or back by touch alone, feeling for tension in the spinal muscles. In almost two hundred patients, they identified the correct side of 65% of lower back pain and 59% of neck pain — only slightly better than chance.
An odd anomaly occurred in the difference between the left and right side: the examiners were more accurate on the right side with back pain, but better on the left side with neck pain.
The results are underwhelming. Although they did a little better than just guessing, the results suggest that it’s difficult even for expert examiners to detect the location of neck and back pain by feel. As well, they were only attempting to detect the side of pain. Imagine how much worse their performance would have been if they had to identify the location more precisely, or if the pain could have been anywhere or nowhere. So they barely passed the easiest possible test, and probably would have failed a harder one and done no better than guessing.
An obvious weakness of the study is that only two examiners (of uncertain skill) were tested, and so the results are inconclusive. One would still hope for a better detection, though, even from professionals with only average examination skills.
- The ability to detect the painful side by feel alone is difficult for reasons that make sense, consistent with what we actually know about how neck and back pain work— that is, they don’t cause obvious, consistent changes in tissue texture and they correlate poorly (really barely at all) with obvious structural problems. Being able to detect nonexistent signs is not actually an important diagnostic skill. 😜
- The skin does get flushed and warm, of course. That’s just superficial, cutaneous hyperaemia: capillaries in the skin respond to mechanical stimulation by dilating (which is likely an immune function: the body transports blood to the site of possible skin breakage). Blood is hot, so the skin gets quite toasty! But it’s clinically trivial and superficial only, and it has nothing to do with the intention of the claim that massage works by increasing circulation.
- Hovind H, Nielsen SL. Effect of massage on blood flow in skeletal muscle. Scand J Rehabil Med. 1974;6:74–77. PubMed 4837058 ❐
- Wakim KG, et al. The effects of massage on the circulation in normal and paralyzed extremities. Archives of Physical Medicine & Rehabilitation. 1949;301:35–144. PubMed 18114696 ❐
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.
- Shoemaker JK, Tidus PM, Mader R. Failure of manual massage to alter limb blood flow: Measures by Doppler ultrasound. Medicine & Science in Sports & Exercise. 1997;1:610–14. PubMed 9140896 ❐
- Hinds T, McEwan I, Perkes J, et al. Effects of massage on limb and skin blood flow after quadriceps exercise. Med Sci Sports Exerc. 2004 Aug;36(8):1308–13. PubMed 15292737 ❐
- Sometimes we feel cruddy after a massage, like it was a big workout. Post-massage soreness and malaise (PMSM) is embraced as a minor side effect and hand-waved away by almost everyone as some kind of no-pain-no-gain thing. But it needs explaining. Massage is not “detoxifying” in any way (that’s pseudoscientific nonsense). Ironically, it may be the opposite: some PMSM is probably caused by mild rhabdomyolysis, a type of poisoning that can occur even with heavy exercise (a medical reality), and possibly strong massage (a plausible hypothesis). If so, it’s a big deal, a serious side effect. There are also some non-rhabdo explanations for milder PMSM. See Poisoned by Massage: Rather than being DE-toxifying, deep tissue massage may actually cause a toxic situation.
- Torres R, Ribeiro F, Alberto Duarte J, Cabri JMH. Evidence of the physiotherapeutic interventions used currently after exercise-induced muscle damage: systematic review and meta-analysis. Phys Ther Sport. 2012 May;13(2):101–14. PubMed 22498151 ❐
This review of 35 tests of treatments for delayed onset muscle soreness (DOMS) is strongly consistent with my own past interpretations of the research: basically, nothing works. Massage is “slightly effective” but “its mean effect was too small to be of clinical relevance.” The evidence for cryotherapy, stretching, and low-intensity exercise is not promising, but technically still inconclusive: more study needed.
- Strong massage is actually mildly injurious, much like a big workout. It’s common for people to be very, very sore for a day or two after massage.
- Crane JD, Ogborn DI, Cupido C, et al. Massage therapy attenuates inflammatory signaling after exercise-induced muscle damage. Sci Transl Med. 2012 Feb;4(119):119ra13. PubMed 22301554 ❐
This study is the source of a new massage myth that massage reduces inflammation. Inspired by the doubtful notion that “massage may relieve pain in injured muscle” after intense exercise, researchers looked for changes in the proteins that cells constantly make (“gene expression”). They compared muscle tissue samples with and without massage and concluded that “massage therapy appears to be clinically beneficial by reducing inflammation and promoting mitochondrial biogenesis.” Massaged muscle was found to be producing different amounts of five proteins related to inflammation and promoting the growth of mitochondria (cell power plants). It was an interesting, technically demanding, and worthwhile experiment, and it’s nifty that there was any difference in gene expression in massaged muscle.
Unfortunately, the results of this study were actually negative: the data showed that massage has no significant effect on gene expression in muscle cells. There are several major problems with the study: the sample size was extremely small; the number of changes they found was trivial (and dwarfed by what exercise causes); the size of the differences was barely statistically significant—and short-lived, too; they measured genetic “signals” and not actual results, and guessed about their meaning; and we already know from clinical trials that massage doesn’t work any miracles for soreness after exercise, so what is there for the data to “explain”? Despite all of these problems, the results were spun as an explanation for how massage works in general — in the paper itself, the abstract, the journal’s summary, the press release, and interviews. Consequently, the results have been widely reported and discussed as if it is now a scientific fact that massage actually does reduce pain and promote recovery, and the only question was “how?” It’s a debacle.
For a much more detailed analysis, see Massage Does Not Reduce Inflammation, or a more technical analysis by Dr. David Gorski at ScienceBasedMedicine.org, Does massage therapy decrease inflammation and stimulate mitochondrial growth?
- Day JA, Mason RR, Chesrown SE. Effect of massage on serum level of beta-endorphin and beta-lipotropin in healthy adults. Phys Ther. 1987;67:926–930.
- Moyer CA, Seefeldt L, Mann ES, Jackley LM. Does massage therapy reduce cortisol? A comprehensive quantitative review. J Bodyw Mov Ther. 2011 Jan;15(1):3–14. PubMed 21147413 ❐
It is frequently asserted that massage therapy (MT) reduces cortisol levels, and that this mechanism is the cause of MT benefits including relief from anxiety, depression, and pain, but reviews of MT research are not in agreement on the existence or magnitude of such a cortisol reduction effect, or the likelihood that it plays such a causative role. A definitive quantitative review of MT's effect on cortisol would be of value to MT research and practice.
- Ingraham. Insurance Is Not Evidence: Debunking the idea that “it must be good if insurance companies pay for it”. ❐ PainScience.com. 900 words.
Practitioners of alternative medicine often imply that they have “great power” by talking up their “great responsibility” to avoid the dangerous side-effects of their allegedly potent methods. It’s a self-serving way to inflate the perception of potency while seeming adult and professional about it! It’s also an easy position to defend, because it makes critics seem reckless — you have to be quite sure of your facts to warn anyone to ignore a safety warning! With the Great-Power Gambit, “everyone wins” except the truth.
Unsurprisingly, the actual harms of alternative medicine tend to get ignored, while mainly the more fanciful ones are exploited for this purpose.
- Smith CA, Armour M, Dahlen HG. Acupuncture or acupressure for induction of labour. Cochrane Database Syst Rev. 2017 10;10:CD002962. PubMed 29036756 ❐ PainSci Bibliography 51735 ❐
This 2017 Cochrane Review tests the validity of the popular belief that stimulating specific acupuncture points can induce labour in pregnant women. It analyzed the pooled results of 22 randomized controlled trials including over 3400 women. They looked for effects on labour induction and “cervical ripening” (softening prior to labour), mostly using acupuncture and acupressure. “Many” of the studies they included had at least some risk of bias, and therefore more likely to bend the data in favour of the belief… which didn’t really happen.
At most, there was weak evidence that acupuncture improves cervical ripening, which is an extremely weak-sauce result, like saying that you’ve captured Bigfoot and then showing off a chimpanzee wearing big rubber feet. Like a lot of meta-analysis these days, there’s almost always some slightly promising signal that the authors cherry-pick (even as they invariably also emphasize the paucity and poor quality of evidence).
In every other way, “there were no clear differences” between any experimental groups for any other outcome, and there was “no clear benefit from acupuncture or acupressure.” If labour induction by acupuncture works at all, it’s obviously an unreliable and minor effect. The whole acupuncture-induces-labour thing is just another alternative medicine myth.
- Wiltshire EV, Poitras V, Pak M, et al. Massage impairs post exercise muscle blood flow and lactic acid removal. Med Sci Sports Exerc. 2010 Jun;42(6):1062–71. PubMed 19997015 ❐
- Plus, this is not the kind of study where a large number of subjects is needed to be convincing. 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.
- This is the Crane et al gene profiling study cited above with regards to muscle soreness (DOMS). Although the study was not particularly about lactic acid, they checked and found that “there were no effects on muscle lactate levels” with massage. (Ironically, their findings may actually replace the lactic acid myth with another myth: that massage “reduces inflammation,” which was their primary exaggerated interpretation of their results.)
- Nytimes.com [Internet]. Kolata G. Finding May Solve Riddle of Fatigue in Muscles; 2008 Feb 12 [cited 15 Feb 20]. PainSci Bibliography 55656 ❐
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.
- Lactic acid is not a dead-end, “bad” metabolic waste product, and it does not cause post-exercise soreness. This is a pernicious and seemingly un-killable myth. It originated with “one of the classic mistakes in the history of science,” according to George Brooks, a Berkley physiologist. I will not give the myth any further air time here. See Gina Kolata’s clear overview in the New York Times, or a concise professional summary by Robergs in Experimental Physiology. For a deeper and geekier, but excellent read, see Dr. Goodwin’s entertaining rant about the prevalence of the lactate myth in the 2012 summer Olympics coverage.
- 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.
- Carnes D, Mars TS, Mullinger B, Froud R, Underwood M. Adverse events and manual therapy: a systematic review. Man Ther. 2010 Aug;15(4):355–63. PubMed 20097115 ❐
The sound bite in this study is that 20-40% of all manual therapy treatments — massage, chiropractic, physiotherapy — will cause some kind of unpleasantness, side effect or “adverse event” in medicalspeak.
In a word: yikes!
Perspective cuts both ways here. On the one hand, it’s not as bad as it sounds: these “events” are minor and moderate in severity; only 1 or 2 per thousand visits causes a serious problem; and drugs are actually relatively worse. That is, you are modestly more likely to have an “adverse event” if you are given a pill. This just refers to typical side effects, such as ibuprofen’s tendency to cause indigestion.
But when you take a pill, the side effect is usually unrelated to the problem (i.e. it doesn’t make the problem you’re treating worse), you are generally trading those side effects for some pretty clear benefits, and it’s usually cheap. In manual therapy, most adverse events are backfires — that is, you go for a neck adjustment at the chiropractor, and you come out with more neck pain instead of less. Other data shows this is 25% more likely than if you did nothing at all (see Carlesso). And you pay through the nose for this! Manual therapy is much more expensive than most drug therapy.
Manual therapists routinely claim that their services are much safer and more effective than drug therapies. Yet this data pretty clearly shows that the difference is really not great. Depending on how you look at it, drugs are only a little worse in some ways, or maybe a little better in other ways. But no matter how you slice it, 20-40% is a pretty unpleasant rate of harm — especially at $60–120/hour!
- Moran RN, Hauth JM, Rabena R. The effect of massage on acceleration and sprint performance in track \& field athletes. Complement Ther Clin Pract. 2018 Feb;30:1–5. PubMed 29389467 ❐
- Goodwin JE, Glaister M, Howatson G, Lockey RA, McInnes G. Effect of pre-performance lower-limb massage on thirty-meter sprint running. J Strength Cond Res. 2007 Nov;21(4):1028–31. PubMed 18076229 ❐
This is small but straightforward and well-designed trial that quite clearly shows that massage had no effect on sprinting, good or bad.
The final sentence of the abstract cracks me up: “Massage remains indicated” for other reasons… that have yet to be challenged by research like this, but almost inevitably will be in time.
- Fletcher IM. The effects of precompetition massage on the kinematic parameters of 20-m sprint performance. J Strength Cond Res. 2010 May;24(5):1179–83. PubMed 20386129 ❐
- There’s less cause for concern when the results are negative (supporting the null hypothesis). An unpowered study can undermine a claim like “pre-sprint massage enhances performance” more credibly than it can support it.
- Wiewelhove T, Döweling A, Schneider C, et al. A Meta-Analysis of the Effects of Foam Rolling on Performance and Recovery. Front Physiol. 2019;10:376. PubMed 31024339 ❐ PainSci Bibliography 52257 ❐
- Ernst E. Massage therapy for low back pain: a systematic review. Journal of Pain Symptomology Management. 1999 Jan;17(1):65–9. PubMed 9919867 ❐
This is a review of four studies, all of which were burdened with “major methodological flaws.” It 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.)
- Pope MH, et al. A prospective randomized three-week trial of spinal manipulation, transcutaneous muscle stimulation, massage and corset in the treatment of subacute low back pain. Spine. 1994;19:2571–77. PubMed 7855683 ❐
- 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.
- As of late 2017, I’m aware of just 16 studies worth knowing about — if you keep your standards low — and all of them have serious flaws, all show signs of a high risk of bias, all claim to be positive while being contradicted to at least some degree by their own actual data. Most report only minor effects, a couple are clearly negative, and just one (Aguilera) reports a more robust effect … but based only on a single measurement taken immediately after treatment, which could evaporate within seconds for all we know.
- 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.
- 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.
- Rathbone ATL, Grosman-Rimon L, Kumbhare DA. Interrater Agreement of Manual Palpation for Identification of Myofascial Trigger Points: A Systematic Review and Meta-Analysis. Clin J Pain. 2017 Aug;33(8):715–729. PubMed 28098584 ❐
This is a meta-analysis of 6 studies of how much different experts can agree on the location of myofascial trigger points (inter-rater reliability). They had to “estimate” an agreement score of 𝛋=0.452 — a rather precise estimate! Of the criteria used to determine the location of trigger points, the most reliable were localized tenderness (.68) and pain recognition (.57).
Those are actually not terrible reliability scores. Obviously they could be better, and it would be nice if they were, but it’s important context that most attempts to detect pathologies in the body are technically “unreliable,” falling well short of a score of κ=1.0 (perfect agreement), but still much better than κ=0 (coin flipping agreement).
And the error bars on those estimates were too large for a confident conclusion anyway.
Therefore, my conclusion is that this review was mostly inconclusive, but actually found evidence that trigger point reliability is probably not all that bad (compared to what you’d expect from a diagnostic procedure for something that doesn’t actually exist).
- Montagu A. Touching: the human significance of the skin. 3rd ed. Harper & Row; 1986. An impressive and well-documented examination of the importance of touching to growth and development, health and well being. Although several other books have been written about the touch since, Montague’s is arguably still the best.
- Cascio CJ, Moore D, McGlone F. Social touch and human development. Dev Cogn Neurosci. 2019 02;35:5–11. PubMed 29731417 ❐ PainSci Bibliography 52553 ❐
In contrast to the dearth of evidence about massage in particular, there is an avalanche of research about the neurobiology and pscyhology of touch. The entire paper is relevant, but for an excellent overview of the effect of touch on growth and development in particular, see section 4, “Social touch over the human lifespan.”
- We are creatures of habit and pattern, a strong property of the way the human nervous system functions. Every time we experience something, we are more likely to experience it the same way again in the future, because perception and sensation are so strongly built on expectations, especially threat assessment. That is, we tend to see and feel what we expect to see and feel, and we are particularly prone to expecting the worst (as a survival strategy). If our expectations are negative and fearful — as they often are, because life is harsh, and trauma is common — that then colours our experiences quite a bit. This is an important principle in chronic pain, which routinely involves “central sensitization,” the brain-driven lowering of pain thresholds, and the ultimate clinically relevant example of a “sensory rut.” See Sensitization in Chronic Pain.
- Example: Despite their rationality, these therapists are usually factoring out several snake oils, because they assume they are legit, and have never gotten around to examining that assumption. For instance, they may consider energy work to be nonsense, but assume that acupuncture is evidence-based — a common and understandable mistake, but a mistake nevertheless. See Does Acupuncture Work for Pain?.
- Emotional Freedom Technique is actually attribute to an engineer, Gary Craig, who wrote a book about it called EFT Handbook, published in the late 1990s.
- For example, the fascinating phenomenon of the tradition of morbidity and mortality meetings, where doctors discuss their mistakes and how to prevent them from happening again).