Does massage therapy “work”? What do massage therapists say that they can do for people and their pain, and is there any scientific evidence to support those claims? In this article, I examine massage therapy in the light of science — 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
Summary of the Article
Many massage therapists offer patients some services of dubious medical value, even where training standards are high (and training standards in most places are low or nil). However, massage therapists get so much hands-on experience that they often learn to serve patients well regardless of limited training. Their successes may be due primarily to the effects of pressure on “muscle knots,” a ubiquitous phenomenon and likely factor in many common pain problems.
Therapeutic massage probably has many subtle and minor benefits, especially pleasure and relaxation: it always has at least that much to offer to patients. But a well-trained “medical” massage therapist can also offer many other useful services, such as rehabilitation coaching and specific evidence-based manual therapies for a variety of injuries and pain problems. For example, a good massage therapist might help a patient with plantar fasciitis not only by providing massage which might be therapeutic, but by recommending an evidence-based self-treatment like stretching and night splints. Such services can be a valuable combination, if a patient can find and afford such a therapist. Unfortunately, in most jurisdictions, massage therapists lack even the most basic training in orthopedics and rehabilitation.
Worse, pseudoscientific beliefs and practices are rampant in the profession, with many practical consequences. For instance, misguided beliefs about detoxification, or the value of trying to “release” certain kinds of tissues, are often used to justify “deep” massage that can be harmful, or at least unpleasant and stressful — spoiling the only definite benefits of an expensive appointment!
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
Types of massage therapists
There are a few “medical” massage therapists out there with some training in orthopedics and rehabilitation. My education in massage therapy here in British Columbia, Canada, was three years long — the longest massage therapy training program in the world. There are also a few other places with two-year programs. A massage therapist with this level of education is certainly the kind that patients should seek out if they want massage as a treatment.
Unfortunately, such massage therapists are quite rare. Most are poorly trained and uncertified. Most work in spas or resorts and on cruise ships, doing treatments that are infamously fluffy and skin deep, with little therapeutic value other than the comfort of a quiet hour of touching (even though many patients find skin-deep massage to be more annoying than anything else). Most of these therapists are earnest and view themselves as medical semi-professionals, despite their comparative lack of training. It’s actually inappropriate to call them “therapists” at all, and in some places (here) it’s actually illegal — they have to use terms like “bodyworker” or “masseuse.”
Interestingly, the most pleasant massages I have ever had were done by therapists of this type! Compassionate and emotionally mature people are drawn to the work and usually think of it as a bit of a calling — perhaps this affects the sensory quality of the experience more than technical training.
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.
Massage Science and Mythology
The trouble with studying massage
Massage can be studied: we don’t have to know how something works to find out if it works. Do people who are sick or broken get better when massaged?3
But logistics, economics, and devilish details get in the way. Not many scientists are interested in studying massage, while massage therapists don’t have scientific training. It’s an expensive and overwhelming challenge for a massage therapist to make room in their career for some research — few do it, and hardly any have ever done it well. Even when they do, you’d be amazed how hard it is to even find 100 people with the same problem, so studies of that size are almost never done: instead you get studies of 20 or 30 patients, which isn’t generally enough to prove much. Another challenge is that “massage” can mean so many things that it’s hard to know what is even really being studied (lack of standardization of treatment).4
More technically and most seriously, massage research is plagued by a “stark statistical error”: the error of reporting statistical significance of the wrong thing, or the wrong comparison.5 Dr. Christopher 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”6
(Dr. Moyer thinks it’s even worse than “in its infancy” — he’s called massage therapy research “stunted”!7 Nevertheless, let’s make of it what we can…)
The scientific case for massage therapy
Massage for low back pain is the most studied massage question, and the answer is fairly clear — it probably works at least a little. More below.
Unfortunately, most other evidence about massage benefits is indirect and/or weak. Some research helps us to understand why people like massage, or why it’s likely that there are numerous minor or general health benefits. But there are no smoking guns, no “proof” that it “works” — that is, we have no clinically significant therapeutic effectiveness for a good variety of health problems.
For instance, basic research has shown that touch is neurologically complex and probably has many physiological effects. In 2009, Swedish researchers identified specialized nerve fibers that respond only to light stroking of a certain speed.8 This is interesting, and it certainly suggests that massage can provide a rich and novel sensory experience — surprise surprise! — but it is far from proof that massage can fix anything.
Another 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 regulation9 — just from pulling on muscles, which may not be very different from pushing on them. It’s pretty reasonable to guess that movement (and manipulation) of soft tissues has systematic regulatory effects.
While many benefits of massage are still disconcertingly uncertain and hotly debated (by some), there are two truly proven ones. Massage researcher and psychologist Dr. Christopher explains that the only truly confirmed benefits of massage are its effects on mood (“affect”),10 specifically:
- massage reduces depression
- massage reduces anxiety
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: it’s relaxing. While not proven as well as you might think, it is a pretty safe bet,11 and the idea is further supported by evidence that massage therapy may reduces blood pressure1213 and helps people to sleep, even when they are under the unusual stresses of hospital care.14 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.
And, as many critics have pointed out, massage is a super expensive way to relax. 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 … but does it work 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.
Many studies done by the Touch Research Institute15 — although almost certainly of generally low quality and strongly biased in favour of massage16 — show many other broadly defined modest benefits to massage therapy in many circumstances—everything from rheumatoid (bad) arthritis17 to cancer18 to autism.19 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.20 (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.21)
When massage isn’t even massage: non-massage treatments
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 ishard 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.2223 In fact, the evidence strongly suggests recovery from nearly any injury or surgery is greatly facilitated by early mobilization.24 But that’s not “massage” — 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, good for one thing and not much else. It’s purpose is to reduce swelling. It may be 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 works nicely, but 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.
There are many other examples of plausible, evidence-based advice and treatments that better-trained massage therapists will know about. But there are also many manual therapy techniques that are surprisingly un-proven, including some extremely popular ones.
Traction is a great example — pulling on the spine. Often used by massage therapists to treat low-back pain and neck pain, it might be an effective technique for a few patients, but I wouldn’t count on it, or advise anyone to spend much money on it. Like many popular therapies, the evidence is a mess.25 The absence of conclusive evidence is significant: if traction worked well, it probably would have shown up clearly by now. If traction works at all, it’s certainly not reliable.
Friction massage, another specific type of massage, mainly as a treatment for tendinitis, 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 — indeed, it has been undermined by it so far.26 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.27
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.28 Some massage therapists believe, while many others believe it’s nonsense.29
Craniosacral therapy is another classic example — popular for decades, it is a touch therapy, not “massage,” and it has never enjoyed any respect from the majority of doctors or scientists. It has even been criticized by many alternative health professionals.30 And yet it is sold with great (over!) confidence by countless manual therapists as though it were proven effective.
There are many other examples of weird and silly treatments. See the further reading list at the bottom of this article.
So “massage therapy” is often not limited just to Swedish massage. The other things that massage therapists do are a real mixed bag of standard manual/physical therapies along with many, many other things.
Massage for back pain: almost evidence-based!
This topic is covered really (really) 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.
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 75% of massage purchases are for back pain. The amount of money that patients around the world spend on massage for back pain must be simply huge, at least in the tens of millions annually, and probably much more. As with chiropractic care, massage therapists might not have much of a business model if people didn’t have low back pain.
So it had better work!
And, fortunately, the evidence seems to suggest that it does, at least a little. Over 20 years, an accumulation of scientific evidence has been adding up to a nice conclusion: that massage therapy probably does work for low back pain. That’s the finding of a comprehensive review of the science, from a 2008 review by Furlan et al:31
Massage is beneficial for patients with subacute and chronic non-specific low-back pain in terms of improving symptoms and function … The beneficial effects of massage in patients with chronic LBP are long lasting (at least one year after end of sessions).
That glowing conclusion was based on just 13 trials (about 1600 participants), and the best data of the lot is merely okay. But massage “wins” anyway. Massage mostly performed quite well in these tests. And, better yet, the results were also positive in the more rigourous tests.32
The largest study of massage for low back pain ever done was published in 2011, and its very credible authors — medical back pain experts Daniel Cherkin and Richard Deyo, in particular — did conclude that “Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months,” but those results were uncertain due to a major flaw, and somewhat overstated.33 It seems to me that the results actually damn massage with faint praise. If massage is good for back pain, shouldn’t the results have been a more a bit more impressive? Despite its “positive” results, this study is a bit of a mood dampener.
So, is massage therapy for low back pain “proven” to be effective? Ha! Obviously not by a long shot. But the science is off to a good start — it’s much more convincing than most other popular low back pain therapies. It’s genuinely promising. Remember, once again, this evidence is examined in much greater detail in my low back pain e-book.
Many experts and skeptics seem to like massage (or at least tolerate it), and few are critical
In the summer of 2009, I attended the Science-Based Medicine conference and The Amazing Meeting 7 in Las Vegas: a huge gathering of skeptics, scientists, and critical thinkers. I was the only alternative health care professional at the conference that I know of. I introduced myself publicly to a couple hundred doctors and scientists as a “skeptical massage therapist.” They were delighted, and for the next four days, skeptics approached me regularly to say, “Hey, that was brave! But massage isn’t quackery, is it?”
It's a fair question. Despite the lack of direct evidence, massage generally seems to get a stamp of approval from medical experts. For instance, you can probably trust the opinion of back pain expert Dr. Richard Deyo: he is openly skeptical about most other back pain therapies, but acknowledges that “promising preliminary results of clinical trials suggest that research on massage should be assigned a high priority.”34
Patrick Wall, the eminent neurologist and pain researcher, writes only a single word about massage therapy in his seminal book about pain: “Delightful.”35
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.”36 That’s surprising tolerance from such a fierce critic of questionable health care.
The approval of skeptics doesn’t mean that massage “works,” and they may actually be giving massage more credit than it deserves. At TAM7, I repeatedly explained to horrified skeptics — who were trying to give me the benefit of the doubt — that my colleagues routinely either sell or endorse virtually every imaginable form of alternative health care, including the silliest: ear candling, crystal therapy, iridology, gong therapy (look it up!) … you name it, there’s a goofy therapy that many massage therapists “believe” in.
But the general approval of smart, critical experts does indicate that the value of massage itself is strongly 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!
Massage for fibromyalgia is less promising
Fibromyalgia is a condition of widespread body pain. It’s very existence used to be controversial, but no longer: now the mysteries and controversies swirl around its nature and treatment, which is difficult. 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 al37 is a good example of what a shabby state massage therapy research is in. Let me be clear up front: I don’t think this paper actually proves anything one way or the other. I think it’s straightforwardly inconclusive. It has a positive sounding conclusion that isn’t really justified and there are major caveats. But tis doesn’t mean that I wouldn’t go get me some massage if I had fibromyalgia. I probably would! But that’s another story. 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. This paper epitomizes the “garbage in, garbage out” problem with meta-analysis. There was virtually no research on this topic worth analyzing to begin with.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 passed 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: whoopty-do. 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.”
When massage goes badly
People think of massage therapy as a “safe” therapy, and of course it mostly is. But things can go wrong. Serious side effects in massage therapy are rare, however, and common side effects are minor. A 2007 survey of 100 massage patients38 found that 10% of 100 patients receiving massage therapy reported “some minor discomfort” in the day following treatment. This would mainly be a familiar slight soreness that is common after a massage — I’m surprised only 10% reported it. The massage must have been quite gentle.
Interestingly, 23% reported unexpected benefits that had nothing to do with aches or pains.
(Also interesting is that this means that most of these patients experienced no noteworthy effect at all, good or bad! Hopefully they enjoyed the massage at the time …)
Another article covers this subject in more detail:
The many myths of massage therapy
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,39 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 feel40 — it’s actually an understandable and unimportant failure,41 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.424344 It’s kind of a silly claim. It doesn’t really matter if massage increases circulation, because even a modest boost would be clinically trivial, dwarfed by the effect of any aamount of exercise. Metabolic demand is clearly the primary driver of circulation. The most optimistic perspective — and it is actually good news, albeit with some caveats — comes from a study that showed that a lot of massage improved “venous insufficiency”45 over several weeks. Unfortunately for the good news, regular brisk walking is very likely still better and cheaper.46 Or you could give a massage, instead of receiving one — it’s quite a lot of work!
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.47 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 gets48 — 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.
Massage reduces inflammation. Um, no. The opposite, if anything.49 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.50 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.51 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 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.52
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.
The lactic acid myths (and detoxification in general)
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, usuallu 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 2010.53
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.54 And then these findings were backed up in 2012 by a rather high-tech study.55 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 except the immediate aftermath of intense exercise (and probably not even then). Recent (2008-2010) research has shown that muscle fatigue and the “burn” that you feel as you exercise intensely is probably caused by calcium physiology, not an accumulation of lactic acid.56 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!57
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.58
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:
So-called “advanced” techniques: the trouble with modality empires
Another 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 modality empires (branded treatment methods). See Modality Empires: A tradition of ego-driven treatment methods in manual therapy.
Is there any evidence that any of them actually work better than ordinary Swedish massage? No. They are all unproven and mostly based on shoddy, self-serving clinical reasoning. 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 pet theory corpses. 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’ll get from most methods.
Next: the bankruptcy of the big idea that is the beating heart of many massage methods, probably most of them.
A great may 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). 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.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!
Trigger points: why massage might help, but usually not all that much
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 every back pain client? Because there are many kinds of both massage and back pain. Results of therapy vary widely with the skills of therapists, and with the specific kinds of back pain brought to them. And so, on average:
- benefits are modest
- benefits are temporary
- benefits are inconsistent
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. The phenomenon, whatever it may be, is generally common and particularly tends to crop up as painful complications of many other kinds of painful problems. Trigger points seem to respond to massage, and thus many such problems can be at least partially helped simply by rubbing muscles in the area, creating some illusion that all problems are muscular problems. Back pain is the classic example.62
If this theory is correct, it would explain the perpetual appeal of massage — maybe it can take the edge off a huge 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 — all trigger point therapy is educated guesswork. Therapists have greatly variable education, skill, and luck in this process. Most simply aren’t that good at it — they can’t be, because muscle pain physiology is obscure, complex, and basically way out of their league.63
For instance, therapists are unable to reliably diagnose trigger points64 — and it is hard to attempt to treat what you cannot even find. And when you have found them, the best evidence-based approach to treating them is simply unknown. There are dozens of distinct approaches to treating trigger points, and not one of them is much more than an educated guess. And every patient seems to respond differently (for instance, some patients have clear cravings for brutal intensities of treatment that would literally cripple another patient).
But countless known and unknown factors influence the outcome of any massage — far too many. The result is a weird mix of potential with therapeutic unpredictability and mediocrity.
Personal growth: a massage benefit that may be impossible to define or measure
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 extend well beyond that, into the territory of emotional and psychological benefits that are virtually impossible to define or measure — and surprisingly potent.
Recently, after a long interval without massage, I got a brief chair treatment. Such relief! After 18 years of study, I still don’t understand why massage is such an intense sensory experience — only that it is, and that it matters.
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!”) transmogrify into revelations with broader significance. Intense and/or novel sensations can be a catalyst for personal growth. Above all, massage reminds us what it is like to feel good, and we often desperately need that reminder. Above all, massage reminds us what it is like to feel good, and we often desperately need that reminder. We may then feel highly motivated to reclaim that sense of well-being in the rest of our lives.
Whether it is the clear goal of therapy, or simply a natural side benefit, the sensations of massage can change your sense of yourself, how it feels to be in your skin, and perhaps bump you out of some other sensory rut — which may give you some leverage on your emotional ruts. It is a well-established fact of neurology that posture and facial expressions are strongly coupled to emotional state. It is likely that this phenomenon extends to the physical manipulations of massage: that being manipulated doesn’t just feel pleasant, but also has much more complex effects on emotions and cognition. And personal growth and emotional maturation probably have some clinical relevance to recovery and healing. See Pain Relief from Personal Growth: Treating tough pain problems with the pursuit of emotional intelligence, life balance, and peacefulness.
Economic pressure and the stereotype of hippy health care
Even in places with high training standards, massage therapists almost always have to sell themselves to clients who are paying hard-earned cash, so it’s not hard to see why massage therapists become habitually overzealous in promoting therapeutic services for which there is little evidence, no evidence, or only a mess of controversial evidence.
The road to intellectual dishonesty is paved with good intentions. When I worked as a therapist, there were times when — confession! — I didn’t bother to explain to a patient that I was selling them a dubious approach to therapy 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 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.
So, does massage therapy “work”?
Hopefully it’s now obvious that this is not quite the right question. Does it work for what? What kind of massage therapy? How do we even define the benefits? Is modest, unreliable, temporary relief from muscle pain a significant enough benefit to base a profession on? Do a few subtleties like “relaxation” add up to “works”?
Good massage therapists are the ones with more training and a bigger toolkit. They do what they can with the tools they judge to be the most useful, and they candidly discuss risks, benefits, evidence, and controversies. 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.
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.