Massage Therapy. Should we recommend it?

Is there a strong evidence base for the therapeutic benefits of massage therapy? A prickly question indeed!

There has been heated debate on this topic, as wilth ALL manual therapies of recent times.

For some, massage therapy has no clinical benefits whatsoever. 

Let's take a look at the latest!

 

One of the biggest problems with massage therapy (MT), is actually defining what it is.

Many times I have spent an ethereal hour at the hands of a 'massage therapist' in some idyllic resort in the "Day Spa", annointed with various lotions and eased into a state of uber relaxation by aromatherapy.

On other occasions, one particularly memorable one at the Australian Institute of Sport, I absolutely believed the therapist was about to rupture my kidneys.

Truly one of the most painful experiences of my life. But.. the funny thing is.. I felt GREAT afterwards! (once i could straighten up)

So what is it about massage therapy? Can we for sure say that we have evidence for the therapeutic benefit of this form of treatment?

Well, it is quite a difficult question to answer, and one of the reasons for this is that there are massage therapists.. and then.. there are massage therapists.

The guys you might encounter in the Day Spa, or on a cruise ship, are unlikely to be highly trained in the basics of musculoskeletal medicine.

They are however, likely to be compassionate, empathetic and emotionally mature people who feel that this work is a 'calling'.

As a result, when you strike a really good one of these therapists, the experience is likely to be something special, enhanced by all the 'fluff" that traditionally accompanies the event.

At the other end of the spectrum, and a much rarer beast, are remedial massage therapists (RMT's), who will have undertaken a certificate based training program that may cover a year or more, and that will arm them with an extensive knowledge of anatomy, physiology and the musculoskeletal system.

These therapists are licensed, and are required to maintain a structured continuing medical education program (CME).

The evidence behind what these therapists do is what we shall examine, because this site is about biomechanics and sports injury, and RMT's are an established part of the sports medicine team.

The most comprehensive massage therapy course in the world comes out of British Columbia in Canada, where a three year, 3000 hour course imparts significant knowledge to highly qualified massage therapists. BC has the most stringent licensing laws for massage therapists anywhere in the world, where it is similar to that required for physiotherapists.

Despite this, massage therapy has taken some heat, most famously in a paper by Stephen Barratt MD entitled "Massage Therapy: Riddled with Quackery".

In this (2006) paper Dr. Barratt asserts that  the American Massage Therapy Association (AMTA) Web site has claimed that therapeutic massage can help with allergies, asthma, bronchitis, spastic colon, constipation, diarrhea, and sinusitis. I would take issue with those claims as well.

Intrigued, I jumped onto this website today, to find there is certainly no mention of this philosophy there now at all. In fact the website offers useful information that allows any browser to make their own decisions.

However, there is no doubt problems exist.

The profession of massage therapy still incorporates techniques like traction thearapy, friction, therapeutic touch (which involes no touching at all but manipulation of the clients "aura"), and even craniosacral therapy, a much embraced therapy within the profession.

There is, however, no peer reviewed scientific evidence for any of these therapies. Does it mean these techniques do not work? Well, with the exception of "aura manipulation", not neccessarily, but is does mean MT's should be careful about the claims they make.

That said, MT is no orphan. Almost every branch of the professions serving health, including medicine, have included therapies not based in science.

When I studied podiatry, there was very little evidence base to what we were taught, and my physiotherapist peers were basing entire treatment programs around "ultrasound", a therapy now comprehensively disproved! Fortunately, both professions now follow the evidence pretty rigorously, and I have a feeling that MT is steadily moving down this path.

Difficulties of massage study

There are some well documented difficulties with a research base for MT that need to be flagged.

The human element in massage delivery and reception opens the door for study issues. Despite similar training, each therapist develops unique method of performing certain strokes.

Likewise, the manner in which a therapist performs a treatment is dependent on several factors, such as mood, time of day, room temperature etc. If a massage can not be precisely duplicated, reliability becomes an issue.

Along these same lines, there are certain intangibles that speak to the efficacy of massage, such as the therapist's intention, depth of pressure, and speed of stroke. These critical components of therapy are difficult to quantify, measure and control.

So, now the big question: Does massage therapy work?

Let's take a look at the recent evidence for the efficacy, or otherwise of massage therapy.

  1. Low back pain

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 massages are for back pain. But.. does it work?

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The evidence  suggests that it does. Over 20 years, an accumulation of scientific data 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 Cochrane Review by Furlan. They concluded that:  

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).

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, from the University of Washington — concluded that

“Massage therapy may be effective for treatment of chronic back pain, with benefits lasting at least 6 months. No clinically meaningful difference between relaxation and structural massage was observed in terms of relieving disability or symptoms.”

Unfortunately, the study was marred by a major flaw, in that participants were not blinded to treatment, which is considered a major research no no.

So, is massage therapy for low back pain “proven” to be effective? Unfortunately, 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.

           2. Delayed onset muscle soreness: Is massage effective?

According to this recent review paper (the lowest form of scientific evidence), yes it is. "Massage has been studied as a treatment option for DOMS with promising results in reducing soreness, yet limited results in performance enhancement. As pain has been recognized as an integration of biopsychosocial events, future study of a more comprehensive treatment approach may be warranted."

There are 2 unequivocally proven benefits of MT.

Massage researcher and psychologist Dr. Christopher Moyer explains that the only truly confirmed benefits of massage are its effects on mood (“affect”), specifically:

  1. massage reduces depression
  2. massage reduces anxiety

On that basis alone.. sign me up!

Dr. Moyer's comment: "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".

This resonates with me and, I am sure, anyone who has experienced the beneficial effects of massage, even if we are uncertain of the pathways.

All this gets back to the inescapable fact that massage is relaxing, and this may well be the reason that new data is now emerging on the benefits of MT on the labour process during childbirth, (an RCT= high level of evidence), helps to reduce blood pressureand may play an important role in the treatment of anxiety, pain and fatigue in cancer therapy.

This paper, "Stem cells, angiogenesis and muscle healing: a potential role in massage therapies?" provides a tantalising glimpse of the future, and the potential role massage therapy may play.

At the end of the day, the really interesting thing about MT is that whilst many are skeptical, and some openly critical, no-one dislikes or even openly challenges MT as being anything but therapeutic!

Even Dr. Stephen Barrett the  anti-quackery activist who  condemns common non-massage practices in massage therapy on his popular website, QuackWatch, comments: “ordinary massage and the legitimate practice of massage therapy should not be categorized as quackery.”

At the end of the day, the oldest of all approvals holds true, and while it is nothing like proof, "the proof IS in the pudding!"

Techniques that have for so long coloured the massage therapy landscape and perhaps sullied the genuine, skillful and dedicated band ot MT's who have a real role to play in the sports medicine team, are slowly dying out.

So all I can conclude, is that what for so long has seemed intuitive, that massage, when applied correctly within the boundaries of what we know today.. really does work...is slowly but surely gaining traction in the medical literature.

Simon Bartold
Director of Bartold Clinical

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