This article is one of a set that looks at myths of common treatments. This one looks at massage. It may be useful to look at my article
why it matters how treatment works, prior to reading.
It’s fair to say that I enjoy a good massage. Hey doesn’t everybody. It does have that feel good factor about it and can certainly make achy muscles feel rejuvenated. It can make us feel relaxed and reduce stress. It can make us move better and this can be helpful for recovery.
Despite this, it can also have some negative effects on our pain experience and cause issues in the long term. It can change the way we think about our bodies as resilient things and lower our confidence in them (e.g. I get pain because I'm tight or because I have too much lactic acid). It can make us focus on things we needn't focus on and take us away from the things we can be doing to help our pain. People can become reliant on massage as often its' effects are short lived. On the opposite side if massage doesn't cure us, this failed treatment often exacerbates our problem.
Often the causes of negative effects are the poor reasoning behind the massage . There are many myths that have hung around massage since day dot (see below for my seven myths of massage). In truth it does not do many of the things that it purports to do. These have often been extrapolated from poor quality scientific studies or gathered momentum from hearsay. People have also wrongly put two and two together to make four. For example massage lowers stress; therefore it must be due to lower cortisol (stress hormone). This is translating a clinical outcome to a biological one and may not be true (keep reading for more information). The other thing that can happen is people get better over time whilst getting massages. This does not necessarily mean massage is making them better, we often get better regardless, our bodies are powerful healers.
In truth we do not fully know how massage works. There is increasing evidence it is due to desensitisation of the nervous system rather than changes in the tissues, but this has not yet fully been established. Being happy with this unknown and accepting massage for what it is - something that can make you feel good can help minimise the risk of massage affecting you negatively. It needn't matter really how massage works and sometimes I feel we go into too much detail to make it sound credible.
For me, massage is a luxury item; it may make you feel better however is not a prerequisite to getting better. A treat rather than a treatment if you like. Rather than using it routinely I prefer to have an honest chat to see whether massage should be part of your treatment. If massage makes you feel good and you are not getting dependent on it, or missing out on other crucial aspects of rehab then crack on. BUT, have it in the knowledge it not be working for the reasons it purports to.
If you have any an injury and are wondering what you need to do to get better
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Seven Myths of Massage
- “Massage helps muscle tightness”
I suspect not many of you have had a massage where you have not been told your muscles feel tight or tense. However the evidence suggests we cannot feel or assess 'tightness' through our fingers. If two different clinicians assess the same person they rarely will come up with the same findings / areas of tightness. Research has also shown that clinicians cannot tell which side of a persons back or neck is painful by touch alone. Other research has founded when blinded to sight and pain, clinicians cannot identify trigger points accurately. In fact they found twice as many in healthy controls than people in pain. Tightness thus, cannot easily be defined nor measured by feeling.
Aside from whether we can accurately assess tightness we also know that tissue texture poorly correlates with pain. People with 'hard ropy' texture may have no pain whilst equally someone with little tension may be incredibly sore. It is important also that we don't confuse tightness with pain. If I push hard enough in to anyone's trapezius I will probably cause pain, this does not mean it is tight. Heck, pinching your trapezius to cause pain is actually is a test used in intensive care to check on the alertness of sedated patients.
I have two interpretations of tightness. The first is when someone has reduced passive range of movement. I think it is reasonable to deem them tight. However often we cannot 100% say what is causing that tightness. Is it our nervous system guarding (rightly or wrongly, consciously or subconsciously), is it joint limitation or is there true tissue shortening. Research would suggest that massage has little effect on the structural length of muscles. Therefore any improvements that we see to range of movement post massage, can be assumed to be due to reduction of the bodies protective systems more than changes to the tissues themselves.
My other definition of tightness is that it is a symptom. It is something you the patient reports, it is your description of what you are feeling. Therapists cannot assess this, it is yours'. In essence it is another way of you describing your pain, it's a sensation. We often see people who are not tight in terms of range of movement but feel tight. For example more than 80% of patients with hypermobility syndrome report tightness and they clearly are not tight in the range of movement sense. Equally there are people with terrible range of movement and no feeling of tightness. Like pain, it really is a complex thing. Massage can make you feel less tight but again it is unlikely due to changes in the structure of the muscles.
One thing I see in people that get massages regularly is that they often feel tight. Now it could be that the people who get regular massages are the people who are tight. It would make sense on the face of it. However I do also wonder whether being told they feel tight or tense time and time again, lead them to feeling tighter. As they focus more and more of ridding themselves of this sensation, the problem only becomes worse. Too much focus on tightness can be a bad thing and can drive pain sensitivity. Therefore the way we interpret and act on feelings of tightness is so important. Ask yourself are you tight or do you just feel that you are tight? If you just feel tight are there other ways to reduce this sensation.
2.“Massage increases circulation”
There is a common belief that massage does this, however there is little evidence that massage dramatically increases circulation.
Sure skin gets warm and can appear flushed with massage however this is just due to the opening of capillaries in the skin and is therefore superficial only. Even if massage did moderately increase blood flow to the muscles active exercise would surely affect it more and so the effects from any increased circulation pales in insignificance.
3.“Massage gets rid of toxins”
This has long been a myth and is ingrained in massage marketing. Aside from the argument whether toxins do actually build up in our body and if they do whether that is a problem, there is little credible evidence that massage can remove them. Lactic acid is one of the more studied toxins and there is no evidence massage removes.it or flushes it out. Some evidence is on the contrary and suggests vigorous massage may indeed increase in toxins. This could be a reason for post massage soreness and malaise. Again exercise has been shown to be more beneficial in terms of reducing lactic acid. Interestingly however this is not linked with decreased pain (Suggestive perhaps that it is not the lactic acid that is causing the pain- shock horror).
4. “Massage prevents DOMS”
People often get massage after exercise in the hope of preventing delayed muscle onset soreness (DOMS). This is an interesting situation to me as it is well known massage can cause next day soreness. There is some low quality evidence to suggest that it can take the edge of the DOMS but not significantly. I can see why it is used in elite athletes as small marginal gains are important but perhaps less so in sub elite athletes. DOMS is a condition that will get better anyway and indeed may be a protective response to prevent overtraining. My advice if you're getting massage for DOMS is save your money and enjoy spending it on something else.
5. “Massage releases fascia”
Fascia is frequently perceived as a factor causing a patients pain. Fascia are very tight sheets of connective tissue that run throughout the body. It is thought by some, that if you 'release' fascia you can cure any number of problems. Releasing fascia often needs vigorous rubbing, pulling and / or pressure. Whilst many can tolerate this and enjoy it, a significant number of people cannot. These often leave feeling more injured than they started despite them wanting to try and like / endure it. Even disregarding the fact that fascial release can make pain worse, there is little credibility for it to be a reason why massage works. It has been proven time and again that fascia is too tough to release by manual pressure alone. Additionally one cannot truly assess its tightness (see myth no1.) and this has led many to debate its relevance.
6.“Massage reduces cortisol / increase endorphins”
No need to go into too much detail here, there again is little evidence and the result is mixed. The studies which prove a positive effect are flawed and the levels often only change for a short period of time. The effects of this transient change in hormone levels on overall well-being are likely to be small at best. That is not to say that massage cannot reduce stress or make us feel happy. Remember we are not people and not just the chemicals within us and lots of things feed in to our emotions.
7.“Massage helps back pain”
Well it does, but only kind of, and often only a little bit and only for a short period of time. It is certainly not a cure for back pain, nor a preventative strategy. Many people who do get back pain are those who get regular massage. Surprisingly there is little evidence for massage to help back pain.
One of the biggest studies found a 30% (2/10 pain) improvement to symptoms of sub acute back pain with 10 weeks of massage. Interestingly however those who got no treatment also improved 10%. My thoughts are that the extra would largely have been a placebo and it would have been really interesting if the nothing arm of the trial had some sham treatment or other type of treatment. I would hope any treatment could decrease back pain by such modest amounts. Even putting custard on someone's back! At the 6 month follow-up there was even less difference between the groups and at a year- none. Simply put back pain gets better and massage as well as many other treatments are often not required. Education and moving normally are key.
