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Reassurance for massage therapists

 •  • by Paul Ingraham
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Weekly nuggets of pain science news and insight, usually 100-300 words, with the occasional longer post. The blog is the “director’s commentary” on the core content of a library of major articles and books about common painful problems and popular treatments. See the blog archives or updates for the whole site.

There are some major issues with massage therapy that many massage therapists are oblivious to. shines a bright light on these, thoroughly, and that crushes the spirits of some massage therapists when they first come across it. That is not the intended outcome! 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 it sooner.

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

  • There are many egregious myths about the effects of massage. A great deal of what everyone believes about massage is demonstrably false, or at least highly doubtful. Some major examples: 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.

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

Graphical quote: “The only true disability is a crushed spirit.”

How massage therapists cope with all this negativity

Massage therapy is not just a job for most practitioners, but an identity and a calling, and when that is challenged there’s a lot of this: 🙈🙉🙊. (If your browser isn’t showing that, it’s the see/hear/speak-no-evil monkey emojis.) Most of them are encountering these opinions and ideas for the first time and quickly throw up walls and reject them reflexively: it’s just too much of an existential threat. They dismiss me as “negative” and get on with their lives and careers without missing a beat.

But some more or less accept the disappointing reality, and some of those suffer a crisis of faith in the value of their work. Countless times over the years I have gotten 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?

It’s even become common for such declarations to crop up in on social media, massage therapists publicly announcing that they’re not sure how they can go on after discovering, asking their colleagues for help. What really tugs at my heart strings is that they aren’t disagreeing with me, but just 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 actually can see the problems.

Please do not despair, rational/ethical massage therapists!

Here are several important comfort points for a therapist enduring this crisis:

  • 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 to point out that out, it’s also clearly not as good. Massage delivers premium hedonism, and at its best it is clearly one of the nicest experiences anyone can ever have. While many massage therapists might feel very disappointed by the idea that massage is “just” luxurious, they shouldn’t.
  • Although massage has almost no “proven” therapeutic effects, what it does have is good enough to single-handedly justify the cost of massage therapy for many patients: its well-tested ability to ease anxiety and depression. 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.
  • Helping anxiety and depression are only the tip of an emotional iceberg. Chief among the unproven but likely benefits are a big category of “other” psychological benefits. 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.
  • 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.1 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.
  • Most notably, massage can almost certainly reduce some kinds of pain at least temporarily, via several highly plausible mechanisms. Even if the effect is no more potent or lasting 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 quite a useful “window of opportunity” to test and push back your limits with a little badly needed exercise.
  • 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. 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. There’s a wide range of quality in skeptical rhetoric, and plenty of it is just sloppy and amateurish. In short, we should take skepticism about massage therapy with a grain of salt.
  • Finally, for instance and most notably, I believe that the 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.

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 massage therapist myself, I found it easy to enjoy 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. To the extent that I engaged in obviously experimental therapies (like trigger point therapy), I acknowledged 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 still written articles about stupid massage myths, of course.

  1. “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. ↩︎