This is a guide for people who are trying to find a good medical massage therapist, mainly for help with chronic pain or injury rehabilitation. I explain why it’s hard, and share some sad/weird tales of bad massage (all too common, I’m afraid). My recommendations are based on a lot of expertise and direct experience.1 I’ll tell you how to shop around for a good massage therapist, and especially a massage therapist who knows a least a little bit about trigger point therapy.2
Here’s how to find a good massage therapist, basically:
I constantly hear from readers who have been dissatisfied with therapeutic massage, and the most common question I get (by far) is:
Can you recommend a therapist in [insert any place on Earth]?
I have been asked a thousand times if I can recommend a therapist in Europe, Asia, India, Africa, Australia … whole continents where I know only a few people, and only thanks to email and Facebook and Twitter. And so, unfortunately, the question is mostly impossible to answer. I really need to know a therapist well before I’m prepared to recommend his or her services…and I don’t know them if haven’t been on their table a few times. Even right here in Vancouver I barely know any therapists that well. And even if I did, they’d soon be too busy to take new patients (or they move, or they retire).
Massage therapy is like pizza: even when it’s bad, it’s pretty good. But when you’re in pain and you really need competent help, your standards go up, and you start to notice that a lot of so-called therapeutic massage is a bit sketchy.
From 2001 to 2010, I systematically asked patients why they left previous massage therapists. The experiment continues in correspondence with readers today. I have heard it all. Excessive pressure is the most common problem, and massage that is only “skin deep” and unsatisfying is a close second. (See The Pressure Question in Massage Therapy for more about that.)The most common reason patients leave massage therapists is “too much pressure.” The second most common? “Not enough pressure.”
But I have also heard a litany of basic problems with customer service. You’ve heard of “best practices” — a bit of a buzzword for the last few years. Well, these are some worst practices in massage therapy. For example:
This is a random sampling from recent conversations, all about therapy with well-trained therapists, all with great credentials and aspirations to give people medically useful treatments.
What’s a patient to do in a sleepy midwestern town in the US, in a state where “medical” massage is simply an unheard of specialization? Where the only massage to be had comes from an old hippy bodyworker who speaks passionately about reflexology and wants know what colour the pressure makes you think of?
I knew I was in trouble the moment I walked into her office: the place reeked of essential oils, enough to give me a headache, her shelves were festooned with crystals, and her walls were covered with Scientology posters. If I’d been just a bit older and wiser at the time, I would have walked out immediately. Unfortunately, I stayed — perhaps out of morbid curiosity.
Cheesy, loud new age music, of course. Violently strong pressures, and total disregard for my requests to ease up. She actually shoved the heel of her hand into my eye socket, apparently by accident — I wonder what she actually intended to do? Rapid, erratic changes in technique, intensity and location — one moment she was wrenching my neck, the next slapping my back, and a few seconds later she was driving her elbow into my kidneys. And so on and on. It felt more like an assault than a massage. She actually shoved the heel of her hand into my eye socket, apparently by accident — I wonder what she actually intended to do? For what purpose, exactly, would you shove so hard and suddenly on any part of a person’s face that you might accidentally miss?!
At the very end, she drenched her hands in some floral scent that made me want to throw up, covered my nose and mouth, and commanded, “Breathe! Deeper! Deeper!”
At the end, great insult was added to injury: not only was it the worst massage I’d ever received, it was also the most expensive at $110/hour.
There are a lot of reasons, but here’s some of the main ones:
A young woman with a long history of completely unreasonable chronic headaches sought treatment from three of my colleagues — three unusually well-trained Registered Massage Therapists.7 These people were my colleagues: what would usually be called “medical” massage therapists most other places, and, in theory, the créme de la créme of massage therapy. Any BC-RMT could walk into virtually any jurisdiction in America and be — by far — the best-trained massage therapist available to that population.
My client had seen three of these elite therapists before coming to visit me, but had not gotten any relief whatsoever. She enjoyed the massages, but unfortunately did not find them therapeutically useful.
I soon found out why.
Not long after I started her first treatment, I checked for unusual sensitivity in her suboccipital muscle group (a “trigger point,” a common source of pain for tension headaches). This is an assessement procedure I consider to be as automatic as breathing for a client with her symptoms — I can’t imagine not doing it. And I immediately found what I was looking for: a highly relevant trigger point, which is exactly what you’d expect to find in about 60% of cases.
What happened next is what makes it a good story. My client said in amazement (emphasis definitely hers):
That’s it! That’s where my headache is coming from! You’ve got it! And no one has ever pressed on that spot before.
Really? Could this possibly be? I asked her to confirm this in detail, because I found it so strange. Looking for and treating suboccipital trigger points is one the most elementary things I can imagine a massage therapist doing for a client with chronic tension headaches. Not only is it a classic spot for massage therapy for headaches specifically, it’s one of the most most useful and pleasant targets for good massage anywhere in the body — “Perfect Spot #1”! And yet three other fancy RMTs had not only missed it, but apparently had not even looked for it — an inexplicable oversight.“No one has ever pressed on that spot before.”
Actually, failing to massage suboccipitally in a headache patient is worse than an “inexplicable oversight”: it seems almost impossible to believe that well-trained massage therapists could make this mistake. But, unfortunately, such failures may be typical of the state of trigger point therapy in the world today — even from “elite” therapists.
I’ll return to the special case of trigger point therapy at the end of this article.
For every therapist I’ve found that I’m happy to work with for a while, I’ve abandoned a half dozen that annoyed me with various kinds of incompetence:
And much, much more. I’ve seen it all. Basically, it’s hard to find good help. Finding a good therapist can be an expensive multi-month project, with hundreds of dollars spent on relationships that go nowhere. But the consolation prize is great: a massage therapist you like and trust is extremely valuable.
When you start with a new therapist, ask for what you want, and watch what happens. Be politely demanding. In particular, be picky about pressure. Ask for more or less as needed throughout the treatment. Be nice about it, but say things like, “That’s a bit too strong for me right there, could I get a little less?” If you get a no-pain-no-gain response, counter with this: “Sure, okay, but I’d still like a little break from the intensity for a couple minutes — I need to catch my breath and relax a bit.” Or, if it’s too fluffy a treatment for your tastes, ask for more pressure.
If your therapist doesn’t seem to hear you, or is dismissive, never go back. This is the single most efficient (and likely) way of eliminating therapists who aren’t worth paying.
Find out what the certification standards are in your state or province. Do some Googling. Does your government regulate massage therapy? How much? What does it take for the massage therapists in your region to become massage therapists? Now that you know what the standards are, use them, and favour the therapists who are well-trained and certified.
Credentials really do not guarantee anything, but they are better than nothing. Look for someone with letters behind their name, preferably a “BSc” (although that’s a long shot in most places), but at least “LMT” or “RMT” (licensed or registered massage therapist). I am not saying that unlicensed bodyworkers can’t be good therapists — some of them are truly excellent — but just that your odds are better with someone credentialed.
Favour therapists who advertise “medical” massage therapy, especially in jurisdictions with low certification standards. It may be a false front, but it usually indicates a therapist who has promising aspirations to professionalism. For instance, it strongly suggests that they are more interested in working with physicians than against them. The odds of finding good trigger point therapy are definitely higher in such offices.
“Sports massage” is much less of a gaurantee, but it’s better than nothing: therapists interested in sports massage are a little more likely to be focussed on sensible goals and techniques.
Practically everyone needs a therapist who is familiar with the concept of trigger points (muscle knots).
You can check on this before you even book an appointment: call therapists and just ask them if they know the work of Drs. Janet Travell and David Simons. Tell them you are looking for a therapist with specific skills. Be an assertive consumer, and just politely ask, as easy as asking for their rate: “Do you know the big red textbooks by Travell and Simons?” If they don’t immediately say, “Of course,” then thank them for their time and hang up the phone.
On the other hand, it’s another kind of good sign if they express any kind of skepticism or concern about trigger point therapy… because knowing that there is a controversy is probably more important than which side of it they are on. A therapist who doesn’t think the the big red books are any kind of bible is likely a well-read and a creative and independent thinker — and more valuable to you than a therapist who has no clear opinion about it one way or the other.
More about trigger points below.
Try it out! If you haven’t seen some sign of progress after your first 3-6 hours of therapy, stop going: you need compelling reason to wait any longer than that for results. There is some “wiggle room” for things getting worse before they get better, but not that much, and definitely beware of excessively poor results, like feeling too sore and sick after a strong massage.
If you’re having trouble deciding whether or not continuing with a massage therapist is worth it, I have several more tips about this in Measuring Progress in Massage Therapy.
You don’t need to teach a therapist trigger point therapy theory from scratch — if you’re knowledgeable enough you can guide them towards the kind of massage that you know is most likely to help you.
Ultimately, I think it’s important for every patient who has struggled with chronic aches and pains to learn about trigger point therapy for themselves. Everyone can benefit from reducing dependence on health care professionals. And if you know your stuff — and if a therapist is compassionate, open-minded, and has an ounce of common sense — there should be no problem with “training” him or her to apply the kind of pressure you would apply yourself if you could.
Of course it would be preferable if your therapist could be your guide, but it’s not a perfect world.
So, study trigger point therapy yourself, learn what works for you — a good idea in any case — and then find a therapist who is happy to take direction and learn with you. This subject — finding and training good help for muscle pain — is covered in much more detail in my trigger points tutorial.
Here are a few things to watch out for, and more specific than standard caveat emptor stuff like “beware of big promises.” Each of these ideas is something I consider to be particularly a problem in massage therapy. If you catch your massage therapist pushing any of these ideas, watch out!
On the one hand, sensitive spots in soft tissue — “trigger points” — are a major factor in chronic pain problems of all kinds. Their clinical significance is extraordinary. It’s amazing how often just a little of the right kind of massage, on just the right spot, is all that people need to resolve an otherwise stubborn pain problem. It’s even surprisingly easy for folks to treat many of their own trigger points.
So you’d think it would be easy enough to get some pro help for these trigger point thingies… right? Alas, no.
Although the idea of trigger points has spread far and wide in the last twenty years, it has spread more like religion than science, and mostly among massage therapists. They are still relatively obscure and controversial. Many doctors and physical therapists have scarcely even heard of them. The one kind of therapist that seems most likely be able to help — massage therapists, professionals who work directly with muscle tissue every day — are often unprepared for challenging cases, or even basic ones, as with the headache story I told earlier in the article.
Massage therapists have many common failings when it comes to trigger points, above and beyond the more general problems with their profession:
And so, myths and bogus treatment concepts have always been rampant in the world of trigger point therapy.17 It’s a mess.
Trigger point therapy does not come standard in massage therapy offices — it is a specialization without standards or regulation. It is not reasonable to expect all massage therapists to understand how to treat serious trigger points properly. Most massage therapists are unprepared to treat anything worse than mild-to-moderate cases of isolated trigger point pain.
And this is why readers from around the world so often tell me that they have “already tried massage therapy,” but got no relief. It’s pretty clear that they didn’t get good good massage therapy. Specifically, the probably didn’t get good trigger point therapy.
So, if you’ve already tried something branded as trigger point therapy, and failed to get good results, do not give up yet!
Now that you understand the problem a little better, here’s one more eye-roller of an example of bad trigger point therapy, and good example of why you need to shop around…
In another common and disappointing scenario, massage therapy is focussed … but focussed on the wrong tissue. This story is about a determined and experienced patient, a middle-aged woman with severe, chronic shoulder pain on the “end” of her shoulder — where an officer’s epaulets would be — and radiating downwards on the side of her arm and through her biceps almost to the elbow. It was a nagging, sickening pain, like a toothache in her deltoid muscle.
She had been diagnosed with a whole bunch of common shoulder conditions — basically all of them.It was a nagging, sickening pain, like a toothache in her deltoid muscle.
What made her case a bit unusual was that she really had given physical therapy and massage therapy a good chance to work. She had seen a massage therapist and a physiotherapist concurrently and frequently for 12 weeks. But she had gotten exactly no relief. And, if two therapists working with a cooperative, diligent client continuously for many weeks hadn’t helped her … what chance did I stand of making a difference?
I cautiously quizzed her about exactly what kind of therapy she had received. “Oh, trigger point therapy,” she said. “She did detailed trigger point therapy on my shoulder muscles.” That sounded good. She almost certainly had shoulder trigger points! Why hadn’t she gotten relief?
“Did your massage therapist ever work here, on the back of your shoulder blade, several centimetres away from the location of your symptoms?”
“Oh, no,” she replied. “No, she only worked here,” she said, pointing clearly at her deltoid and biceps — the exact location of the symptoms.
Uh oh. Well, there’s your problem, I thought.
“Twelve weeks of that?” I asked. “Only there?”
She nodded. “Why? Is that bad?”
Yes, that is bad.
The most interesting characteristic of trigger point pain — the main thing that makes treatment tricky — is a phenomenon called “referred pain.” The body, somewhat inept at precisely locating internal pain, experiences muscle pain in a broad area around or near a trigger point … exactly like heart attacks are felt in the arm as well as the chest. The pattern for each muscle is distinctive, almost a fingerprint.
Her therapists had never checked a likely cause of this particular pattern of symptoms — which happens to be the infraspinatus muscle on the back of the shoulder blade, several centimetres away from the symptoms. Infraspinatus trigger points have a highly predictable pattern of referred pain — knots in that muscle cause pain on the end of the shoulder, and the side and front of the upper arm, exactly like this patient’s symptoms.
Every massage therapist should know this. A massage therapist who doesn’t know it is flying blind, doing massage that is about as therapeutic as a manicure.
This is what patients face, trying to get help for countless frustrating pain problems — pain problems that don’t make it onto the medical radar, but are quite capable of reducing quality of life drastically.
So what happened? Her shoulder problem, after almost a year of misery and misdiagnosis, was 100% relieved by a single dose of infraspinatus treatment. Just one properly directed massage. She sure was happy!
It doesn’t always go quite that smoothly, of course. A therapist may have to spend a fair bit of time looking for sensory relationships like this, and it can be tricky even if when single trigger point really is the only problem. But the point is that any good therapist will be trying to do that. Without knowledgeable exploration, it can’t be good trigger point therapy. And there should be pleasant, satisfying massage along the way — that’s the valuable consolation prize, if hunting for and prodding trigger points should fail to produce therapeutic results, which is of course all too possible.
I am a science writer, former massage therapist, and I was the assistant editor at ScienceBasedMedicine.org for several years. I have had my share of injuries and pain challenges as a runner and ultimate player. My wife and I live in downtown Vancouver, Canada. See my full bio and qualifications, or my blog, Writerly. You might run into me on Facebook or Twitter.
Do you have an hair-raising story to tell about massage therapy? Send it along, and let me know if you’re willing to have your name attached to it.
This gentleman asked to stay anonymous, but he was very eager for me to share his story. “If my note will help just one other person, it's worth my time and yours!”
And some follow-up a few months later:
There’s a guy at my gum who is trained in deep massage therapy. I asked he could try to help a stubborn old should injury that was always paining me. The session was 15 minutes and he knew my medical history. He used deep pressure working on the “knots.” It was excruciating! He knew it because I almost left the session. I had the sense that he was fixated on no pain, no gain.
I stuck it out. I almost puked after the session and felt a malaise that lasted for 24 hours. I hurt. I hurt badly. For 3 nights I could not sleep. My shoulder was wicked sore…just like when it was injured prior to the assessments for surgery and the cortisone and physio treatments.7 days after I felt my arm being almost pulled out of the socket, I am still stiff & in pain.
I took pain relievers that had no effect. Ice too. I was a walking sore zombie on drugs with an ice pack.
I had impingement and serious inflammation. From my prior experience, this happens when I am rough on the shoulder and do things I can’t do. But this was much worse and much deeper in the shoulder joint. I had worked for 18 months, 3 times per week in a gym — shoulders, back, core, chest, biceps and triceps — I was careful and made huge gains in strength and in well being. I was healthy and content.
Now, 7 days after I felt my arm being almost pulled out of the socket, I am still stiff and in pain.
Your article hits the key points on the role of the therapist and the care they need to apply. I had “ugly” therapy and it should not have occurred.
I am pissed off and demoralized. I assume that I will have to start over, as if I had just strained my rotator and it was a new injury.
Following my note to you, I met with the therapist/trainer. He listened and was truly sorry. He knew that I had problems following our session because I was not back in the gym for a month, and following that, I was pretty timid. After 6 months, I felt better. But I have a chronic shoulder problem which is worse than prior to this treatment. I understand that his massage therapy has changed, and he is far less aggressive.
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.BACK TO TEXT