Clients often ask me how we are going to know whether or not massage therapy is “working.” Sometimes it’s easy: you know it’s working when you feel better! But many cases are not so straightforward …
Consider the example of iliotibial band syndrome, a common injury that stops runners in their tracks. Resting is a crucial part of therapy, yet you can’t tell whether or not it’s healing without trying to run. How are you supposed to tell what’s happening without testing it out?
Here are some technical indicators that we use to evaluate progress in massage therapy.
Symptom relief is absolutely the bottom line! If your symptoms aren’t improving with a reasonable period of time, therapy isn’t working. There is some “wiggle room” for things getting worse before they get better (see below). As a general rule of thumb, though, you should question the value of any therapy if your symptoms aren’t improving, whatever they are.
About 3–5 hours of massage therapy, give or take, should be enough to get rid of some symptoms. Allow a little more for more severe or older problems, a little less for minor, fresher ones.
It’s not impossible for some problems to require significantly more therapy. However, large investments of time and money should be approached very cautiously, and only with therapists who have really earned your trust
Bear in mind that the disappearance of symptoms does not actually mean that therapy worked. Maybe it did, and maybe it didn’t. It’s common for many problems to naturally get better in approximately the same span of time that it takes to complete a few sessions of therapy, creating an almost perfect illusion that it was the therapy that did the trick.
EXCERPT Parts of this article are excerpted from a much more detailed tutorial about myofascial trigger points. There is also some original content not found in that tutorial. However, if trigger points are your main concern, the tutorial has much more information about how to evaluate progress.
It is usually possible to carefully test the sensitivity of injured or dysfunctional tissues without risking aggravation or compromising overall progress. The condition of a slightly inflamed tendon, for instance, can be determined just by poking it — “provocative testing.” A few seconds of uncomfortable prodding is not going to do any harm, but it will provide valuable information about the state of the tissues.
There are a wide variety of other clever testing methods that can reveal problems by slightly provoking them. This is called “special orthopedic testing,” and entire textbooks are devoted to these almost diabolical tricks of the trade — countless ways of stressing tissues to gauge their health and integrity.
For instance, in the case of iliotibial band syndrome, there is a certain way of moving the knee and that clearly reveals the pain of the syndrome even in someone who normally has symptoms after a lot of running. The test is called the “Noble compression” test after the doctor that invented it. It’s really just a slightly elaborate version of “poking it,” however!
As therapy continues, a therapist may repeat provocative tests to try to evaluate progress.
Trigger point sensitivity … and twitchiness
Myofascial trigger points — muscle knots — are the primary cause or a significant complicating factor in a wide variety of pain problems and injuries. To the extent that they are relevant to the problem, their sensitivity — as felt by you — is a good barometer of progress.
As trigger points “release” and become less sensitive, I invariably increase my pressure to the point where it feels just as sensitive as it did before. This is not usually obvious. Clients are somewhat at my mercy — you have to take my word for it when I tell you that I am using twice as much pressure as last week.
Another good indicator of trigger point release, which is mostly up to me to detect, is reduction in a phenomenon called “local twitch response” (LTR). A nasty trigger points often twitches when stimulated with precise pressure. If the LTR goes down, the trigger point is probably getting better.
Note that changes in the texture of muscle tissue are not reliable indicators of progress. Trigger points are all too capable of remaining hard and rigid even when feeling better — and vice versa (feeling worse without hardening).
Peeling the onion
A classic sign of progress that doesn’t necessarily seem like progress is, believe or not, new and different symptoms replacing the old ones.
The human nervous system seems to “prioritize” problems, letting you know about them — in the form of pain and other symptoms — in their order of importance. As one “layer” of a problem begins to resolve, patients routinely experience a sudden shift in the quality or location of symptoms.
Consider the case of a man with severe chronic low back pain — he’d had symptoms on the right side for about thirty years. After three treatments, suddenly the pain switched sides, just hopped across the spine, a mirror image. He had never felt pain on the left side ever before. This is a real case. This really happens! And it is usually an excellent sign of progress, of things shifting and changing.
Returning to our iliotibial band syndrome example, recovery can be associated with new aches and pains springing up around the lower body, indicating a shift in biomechanics.
Some bad signs
A common discouraging sign is no sign at all: nothing changes. In almost all cases, something should change, either for better, or even for the worse at first. But if nothing at all happens after the third treatment, massage therapy is probably not going to do the trick for you.
Or, it might still work … but inefficiently, slowly, expensively.
Certain kinds of bad reactions are quite typical, and should not be discouraging:
- mild wooziness and dizziness and headaches are common responses to massage therapy in people who are not used to it
- a bruised feeling is also typical when you’ve been massaged for the first time in a while
- moderate aggravation of symptoms after the first and second appointments occurs in about 50% of cases
- actual bruising is rare, but doesn’t usually mean much
But other kinds of negative reactions can be bad news. More serious versions of any of the above: more serious dizziness, headaches or nausea are especially important warning signs. Anything worse than feeling “a little off,” especially after unpleasantly deep “deep tissue” massages, should be considered a genuine adverse effect and not acceptable: see Poisoned by Massage. If you vomit or feel extremely disoriented or dizzy immediately after an appointment, something serious may have gone wrong and you should take yourself to the ER on a better-safe-than-sorry basis. For a hair-raising story of therapy that caused symptoms like this, see What Happened To My Barber?
If your symptoms are significantly aggravated for more than a few hours, if you feel extremely tender or if you have major bruising, that’s not a good sign either.
But, again, for most people the worst sign is simply no sign at all. Something should change within those few appointments.
More information about evaluating progress in trigger point therapy
Relief from the pain caused by muscular trigger points is arguably the best goal for most massage therapy. Unfortunately, sometimes trigger points can be awfully stubborn!
To a great extent, massage therapy is all about relieving the pain of trigger points … or should be? On the one hand, trigger point therapy can provide particularly excellent bang for buck in treating trigger points: a straightforward, highly evidence-based treatment for a muscle problem than can often be easily relieved. How great is that?
But on the other hand, sometimes trigger points are amazingly numerous and/or stubborn, and so many massage therapists are untrained in trigger point therapy that it many patients may get less-than-perfect results.
Knowing as much as possible about how to evaluate progress can be extremely important to a patient with severe trigger point pain. If muscle knots are your main concern, visit the e-book that this article is an excerpt of. Buy it now or read the first few sections for free.
About Paul Ingraham
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.
- The Pressure Question in Massage Therapy — What’s the right amount of pressure to apply to muscles in massage therapy and self-massage?
- How to Find a Good Massage Therapist — Lots of tips for finding good quality medical massage therapy in your area (especially trigger point therapy)
- Does Massage Therapy Work? — A review of the science of massage therapy … such as it is