Reassurance for Massage Therapists

How ethical, progressive, science-respecting massage therapists can thrive in a profession badly polluted with nonsense

Paul Ingraham • Jun 3, 2023 • 10m read

Although this is addressed primarily to massage therapists, and massage has some unique advantages, much of it is also relevant for physical therapists, chiropractors, and osteopaths.

There are some major issues with massage and most other manual (hands-on) therapies that many professionals remain unaware of. PainScience.com shines a bright light on these. That reality check crushes the spirits of some massage therapists when they first come across it.

That is not the intended outcome! I sincerely love massage and always have, despite my reputation for debunking it, and I am not in the business of spirit-crushing. So I’d like to do some damage control — and I’m sorry I didn’t do this sooner in my career.

What are these massage “issues” of which you speak?

I can’t offer (positive) reassurance without explaining the (negative) reasons for why reassurance is needed in the first place. Here is a summary of all the bad news about massage therapy. All of these issues are explored in great detail around this website, and there’s a complete reading list at the bottom of the article:

• There are many egregious myths about the effects of massage. Much of what everyone believes about massage is demonstrably false, or at least highly doubtful: it doesn’t increase circulation, detoxify, or treat exercise soreness.
• The idea of “medical” massage — massage that can measurably help people recover from injury or illness — is tough to defend from a scientific perspective. There are almost no evidence-based benefits of massage, despite appearances to the contrary (there are a bunch of shabby little studies whose results don’t actually show much).
• Although people love to love massage and tend to “give it a pass” even in a skeptical context, the profession has an extremely strong and well-deserved reputation for being “flaky” and embracing and promoting snake oil. It’s pretty bad. Massage therapists say some seriously weird shit.
• Continuing education in massage therapy is mostly a disaster, dominated by pseudo-celebrity gurus whose books and workshops are scientifically bankrupt and intellectually dishonest. See Modality Empires: The trouble with the toxic tradition of ego-driven, trademarked treatment methods in massage therapy, chiropractic, and physiotherapy.

Ew! That’s rather a lot for the profession of massage therapy to be ashamed of.

How massage therapists cope when the problems are pointed out

Massage therapy is not just a job for most practitioners: it’s usually more of an identity and a calling. Many call themselves “healers.” When that identity is challenged, there’s a lot of this: 🙈🙉🙊 or 🤬. Many pros encounter these opinions and ideas for the first time here, and they reject them reflexively: it’s just too much of an existential threat to process. They dismiss me as “negative” and get on with their lives and careers without missing a beat.

But some new readers more or less accept the disappointing reality, and some of those suffer a crisis of faith in the value of their work. A surge in uncertainty about the nature of health problems and what to do about them can be highly corrosive to professional satisfaction.1 Countless times over the years I have gotten poignant notes from therapists like this:

I don’t know what to do! I’ve read everything you have written about massage therapy. I didn’t want to accept any of it at first, but I couldn’t actually argue with much of it. Now I’m questioning everything, feeling embarrassed by my profession, and wondering what the point is. How can I even continue selling massage therapy in good conscience?

Such declarations even crop up on social media, massage therapists publicly announcing that they’re not sure how they can go on after discovering PainScience.com (or kindred sources), asking their colleagues for help. It’s nice that they aren’t disagreeing with me, but it really tugs at my heart strings that they are feeling awful about agreeing with me. Ouch.

I need to do some work to protect those massage therapists from that feeling, if I possibly can. Because I didn’t get into this business to crush spirits! Especially the spirits of the more admirable therapists who can acknowledge the problems.

Please do not despair, rational/ethical massage therapists!

Here are several important comforting points for a therapist enduring this crisis. Although some claims are made here, I don’t do my usual thorough referencing.2

• Massage is pleasurable and relaxing regardless of whether it has any other specific therapeutic effects, and pleasure and relaxation are inherently valuable. While a nap is cheaper, and it’s fun and provocative for a skeptic to point out that out, it’s also clearly not as good. I mean, c’mon, it’s not even close: massage can deliver premium hedonism, and at its best it is clearly one of the nicest experiences anyone can ever have. It’s even full of triggers for the delicious, weird sensory phenomenon of autonomous sensory meridian response, which is probably a symptom of a very therapeutic state of the nervous system. While some massage therapists might feel let down by the idea that massage is “just” a luxury, they shouldn’t.
• Massage can ease anxiety and depression — it’s one well-tested benefit. Although massage has almost no other “proven” therapeutic effects, what it does have is good enough to single-handedly justify its cost for many patients. That’s a big deal. That’s a huge benefit, even if it is the only one that clears the high bar for “proven.” And it’s probably not the only benefit — just the only one that’s solidly evidence-based.
• “Other” psychological benefits. Helping anxiety and depression are only the tip of an emotional iceberg. Chief among the unproven but likely benefits are a sprawling category of “other” psychological benefits, poorly defined and studied, but very likely real and profound. Touch is profound for primates, and massage can probably inspire and facilitate personal growth and awareness in ways that are extremely difficult or impossible to deconstruct, test, and/or even define.
• It’s okay for massage to be “experimental,” and there are several more likely benefits beyond the psychological and “spiritual” that do not need to be proven to be worth using. Evidence-based medicine isn’t paralyzed by imperfect or incomplete evidence, and massage therapy doesn’t have to be either; uncertainty is normal in healthcare, and there are good and bad ways of coping with it.3 Experimental therapy is ethically acceptable, as long as that is how it’s presented (informed consent goes a long way), it’s relatively safe, and it makes sense and doesn’t actually fly in the face of established science. There are several possible benefits of this kind.
• Massage can almost certainly reduce some kinds of pain, at least temporarily, with a variety of highly plausible mechanisms. For instance, counterstimulation is a well-documented mechanism for minor touch-induced analgesia; but just the right kinds of sensations (basically really nice ones) might mediate a beefier analogous effect.4 Even if the result is no more robust than you’d get from an Aspirin, it’s still a valuable ancillary benefit — especially in a rehab context, where a relatively pain-free period can be a useful “window of opportunity” to test and push back your limits with a little badly needed exercise.

Thanks to the Massage Therapist Development Centre for this nice little infographic, concisely explaining the touch/sensation related benefits of massage.

• You can safely take some massage “skepticism” with a grain of salt. The skeptical community is generally well-educated and bright and is mostly correct about the major myths of massage therapy, but it’s also as imperfect as any human community and is not remotely right every time they pipe up. There’s a wide range of quality in skeptical rhetoric, and plenty of it is just sloppy and amateurish. Scientism does exist, and it’s primarily skeptics who are guilty of it (even if we are often accused of it unfairly). Skeptics are as vulnerable to cognitive distortions and motivated reasoning as anyone else, despite their awareness of them; some of them are sociopaths, egregious pedants, even misogynists and racists; many are more committed to their “tribe” than they are to the truth. Finally, for instance and most notably…
• Gripes about trigger point therapy may not be the best work of the skeptical community. Yes, trigger point therapy is indeed scientifically half-baked and badly over-hyped, but that doesn’t mean it’s completely useless or anywhere near as scientifically bankrupt as homeopathy, reiki, or chiropractic adjustment of babies. In my opinion, the topic remains genuinely interesting, the controversy is legitimate and worthwhile, and trigger point therapy can be ethically delivered as a conservative experimental therapy. This is a substantial saving grace for the profession. At least for now.
• Good health care is a process that is greater than the sum of its parts, rather than just a “service” or “product.”5 This can easily get eclipsed in massage therapy because it is so strongly defined by the very specific act of touch and pressing that people are primarily paying for. Chiropractic is similarly constrained by spinal manipulation, and physical therapists are to some extent still disappointingly defined by the provision of electrotherapies and “advanced” exercise prescription. But none of these professions should restrict themselves to just selling their band-aids. There is a bottomless pit of opportunity to make massage just one part of a process that is greater than the sum of it parts. Which basically means being an expert coach/consultant to your patients. That said, the service/product of massage is intrinsically valuable — an advantage almost unique to massage.

Coping with a love/hate relationship

Let me ask my wife how she does it… •sad trombone•

I truly love massage. I also hate all the bad ideas that pollute the profession. But these things are both allowed to live in my brain. They co-exist peacefully, like good roommates.

When I was a massage therapist myself — so very long ago now — I often thought saw seemingly impressive clinical results. As I studied the science of massage other hands-on therapies, I eventually realized that I couldn’t take much credit for that. After subtracting all the confounding factors, delusions and illusions, plus all the genuine perks of a strong “therapeutic alliance,” what was left? What genuine treatment effects, what biological benefits unique to massage?

Those fell well short of “miraculous” and were probably more like, um, “occasionally slightly helpful.” 😕

But here's the thing: that’s not nothing! It really isn’t. And neither are the non-specific effects of any kind of compassionate healthcare. And there are probably some specific effects of massage. And so I found it easy to enjoy my work despite my cynicism about the profession. I just stayed focused on creating an interesting, safe, pleasant sensory experience, because I knew that was inherently valuable even if nothing else was — but something else probably was occasionally slightly helpful. To the extent that I engaged in obviously experimental therapies (trigger point therapy), I made a point of acknowledging the uncertainties and my own ignorance. I asked a lot of people, point blank, if they wanted to pay for experimental therapy… and that didn’t ruin my career. It just led to a lot of useful and interesting conversations about the pros and cons.

I built a busy and satisfying practice on those principles, and I think any massage therapist can.

“But Paul,” protests any reader who knows my story, “didn’t you actually leave the profession because you were disheartened by it?”

Yes, that’s the awkward truth! But I can explain, I swear. I was also being seriously harassed by my licensing agency, which is not an ordinary problem to have. And, of course, I was actually a writer at heart and keen to get on with my true calling. Most massage therapists don’t have sticks or carrots that big pushing and pulling them out of the profession; without those mighty incentives lubricating my path, I would have just fought to stay.

And I still would have written articles about stupid massage myths, of course.

Massage is still a good thing, I pinkie swear.

All the massage myths

The major myths about massage therapy are:

• Massage increases circulation. Probably not… and definitely not as much as a little exercise.
• “Tightness” matters. The three most common words in massage therapy — “you’re really tight” — are pointless.
• Massage detoxifies. It’s actually the opposite, if anything.
• Massage patients need to drink extra water to “flush” the toxins liberated by massage.
• Massage treats soreness after exercise. Studies have shown only slight effects.
• Massage reduces inflammation. An extremely popular belief based mainly on a single seriously flawed study.
• Fascia matters. The biggest fad in the history of the industry.
• The psoas muscle is a big deal. The most overhyped single muscle.
• Massage stimulates endorphins (natural opioid) and reduces cortisol (stress hormone). They do not.
• “Trigger points” are evidence-based. Actually, the science is seriously half-baked.
• Massage therapists have spooky palpation skills. No, it’s just ordinary expertise… and misleading.

The complete list of dubious ideas in massage therapy is much larger. See my general massage science article. Or you can listen to me talk about it for an hour (interview).

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:

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Related Reading

• Why “Science”-Based Instead of “Evidence”-Based? — The rationale for making medicine based more on science and not just evidence… which is kinda weird
• Science versus Experience in Musculoskeletal Medicine — The conflict between science and clinical experience and pragmatism in the management of aches, pains, and injuries
• Alternative Medicine’s Choice — What should alternative medicine be the alternative to? The alternative to cold and impersonal medicine? Or the alternative to science and reason?

Notes

1. Begin AS, Hidrue M, Lehrhoff S, et al. Factors Associated with Physician Tolerance of Uncertainty: an Observational Study. J Gen Intern Med. 2022 May;37(6):1415–1421. PubMed 33904030 ❐ PainSci Bibliography 51391 ❐

   This survey of doctors found that a low tolerance of medical uncertainty was linked to much more burnout, low job satisfaction, and lower “engagement” at work.

   No doubt it’s the same for many other kinds of healthcare professionals as well. But many alt-med practitioners are likely happier in their work due to the illusion of certainty provided by ideologically-driven overconfidence in simplistic and fanciful ideas about health: they really do think that they know what’s wrong with people and how to fix it. Which must feel great!

   The only real solutions for medical uncertainty are probably emotional and philosophical. Education can help, but it certainly can’t cure it! “The more you learn, the less you know.” Any serious attempt to learn leads to an inevitable confrontation with the abyssal depths of our own ignorance! 🕳 (That’s a “hole” emoji there: it may not render clearly or consistently on all devices.)

2. The point here is not to build a scientific case for massage, but to provide a high-level overview of reasons for optimism in spite of how hard it is to do that. But I do make that case as rigorously as I can in my main article about massage therapy: Does Massage Therapy Work? A review of the science of massage therapy … such as it is.
3. “Proof” is an exceptionally high bar, rarely cleared, because the evidence is routinely incomplete/conflicting, and there are both good and bad ways to bridge the gap between the inevitable scientific uncertainties and clinical decision making. The bad ways of coping are appeals to authority, tradition (“we’ve always done it that way”), fanciful mechanisms, etc. But massage therapists should follow the example of good doctors who, faced with imperfect evidence, also assess the plausibility and relevance of treatment claims, explore the potential risks and benefits with the patient, and so on. Many treatments that are less than “proven” can be ethically prescribed if approached in this way.
4. Basically sensation-enhanced descending modulation of pain. I explore this 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.
5. Silvernail J. Manual therapy: process or product? J Man Manip Ther. 2012 May;20(2):109–10. PubMed 23633891 ❐ PainSci Bibliography 54128 ❐ “Published trials of an impairment-based manual therapy approach where the treatment is provided by highly-trained clinicians using manual therapy in the context of a systematic, hypothesis-based clinical reasoning process have consistently shown large effect sizes in validated outcome measures relative to other interventions.”