The Rise of Massage Therapy in Pain Management

 By Donna Shryer, May 1, 2022

Statistics from the National Health Interview Survey (NHIS) show that 50.2 million adults in the U.S. experience chronic pain on most days or every day. Put another way, 1 in 5 Americans aged 18 years or older are limited in their daily functioning and productivity.¹ 

One tool to ease the nation’s chronic pain epidemic is prescribed narcotics—or opioids—which bind to receptors in the brain and block pain sensations. To be clear, the National Institutes of Health deems these drugs effective at reducing pain “when used carefully and under a qualified health care provider’s direct care.”²

However, the National Institute on Drug Abuse reports numbers that suggest a one-size-fits-all approach to narcotics for anyone suffering chronic pain is not the answer.   

Between 8 and 12 percent of people using an opioid for chronic pain develop an opioid use disorder.³

In 2020, an estimated 2.7 million Americans aged 12 or older reported having an opioid use disorder within the past 12 months—including 2.3 million people with a prescription opioid use disorder.⁴

Reframing the Pain Management Conversation: The Rise of Massage Therapy 

With narcotics no longer the universal solution for pain management, medical practitioners and patients alike are seeking nonpharmacological medications, therapies, procedures, and techniques that can treat pain but won’t create new challenges. 

In recent years, integrative health care approaches to pain management have taken center stage as the opioid epidemic has pushed everyone to find new ways to deal with chronic pain. The result is a new view as to who’s at the forefront in chronic pain management.  

Scientific studies support this emerging dream team. One study, titled Living Well with Chronic Pain and published in Pain Medicine,⁵ found that patients suffering from chronic pain who participated in a multidisciplinary, nonpharmacological treatment approach delivered via shared medical appointments experienced reduced pain and improved measures of physical, mental and social health without increased use of opioid pain medications.

Irina Todorov, MD, one of the study’s authors and medical director, Cleveland Clinic Center for Integrative and Lifestyle Medicine, says the study’s evidence supports the importance of a multidisciplinary team to treat chronic pain. “This is how we can build a highly individualized, multimodal treatment plan.”

The ideal pain management team, Dr. Todorov adds, begins with the primary care physician (PCP). “The PCP is like a conductor who coordinates care between every specialist, including a behavior health specialist, manual therapy specialist, nutritionist, surgery and pain management specialist, and integrative modalities like acupuncture. In our department, we are fortunate to have a chef, who teaches culinary medicine, and yoga/tai chi instructors.”

How do all these specialists promote highly individualized care? Dr. Todorov explains. “If I see two patients with low back pain, one might go home with a prescription for anti-inflammatory medication, physical therapy and warm compresses. The other patient might benefit most from massage therapy and a consultation with a behavior health specialist,” she says. “These are two very different approaches, yet depending on the individual patient, both can achieve reduced pain and improved measures of physical, mental and social health.”

The Role of Research 

Specific to massage therapy, manipulation of the body’s soft tissues has been missing from the pain management plan for far too long, says Sarah Lashley, LMT, certified precision neuromuscular therapist, clinic director, Somavida Pain Relief Center in Evanston, IL. “There’s no clear focus on myology in our medical system. The physical therapy curriculum comes close, but it doesn’t address trigger points, fascia and soft tissue problems.” Lashley adds. “Massage therapists, with our  unique knowledge of muscles and specialized skills for working with soft tissue problems, fill that gap on a traditional medical practitioner’s team.”

However, before massage therapists can officially take their place, the medical community needs more high quality, randomized controlled trials to bolster understanding of massage therapy’s safety, efficacy and mechanisms of action. 

Understanding the mechanism of action is key before any drug, therapy or treatment can impact clinical guidelines, and that includes massage therapy, explains Helene Langevin, MD, director of the National Center for Complementary and Integrative Health (NCCIH) headquartered in Bethesda, MD. “We need to know why applying a certain amount of physical force to a tissue achieves different results, and we also need to know how much physical force is necessary to achieve desired results, which is dose,” Dr. Langevin says. “When you understand exactly what happens in the tissue, it strengthens our evidence that massage therapy is safe, effective and should be incorporated into clinical guidelines.”  

On the topic of evidence, Dr. Langevin reports “good news.” For example, evidence initiated a significant change in the American College of Physicians’ clinical guidelines to manage acute and subacute low back pain.⁶ As of 2017, treatment recommendations were enhanced to include massage, acupuncture, spinal manipulation, tai chi and yoga. “This is no small matter,” Dr. Langevin emphasizes.

There are also meta-analyses that point to massage therapy’s ability to improve quality of life and relieve pain experienced by patients with fibromyalgia⁷ and breast cancer survivors.⁸ “As evidence is disseminated, it becomes clear that the massage therapist needs to be on these patients’ healing teams,” Dr. Langevin says.

In addition, there’s research investigating massage therapy’s effect on myofascial pain syndrome. “At this point, we know that when certain manual therapies are applied to sensitive points in a muscle, pain can improve,” Dr. Langevin says. “But until we can measure what goes on in the tissue, before and after application of different types and doses of manual therapy, we can’t change the clinical guidelines for treating myofascial pain syndrome. I’d like to think that the current research will move the needle here.”

Being Taken Seriously in Pain Management: What Massage Therapists Need to Know

As randomized controlled trials deliver hard evidence that massage therapy is a nonpharmacological treatment to reduce pain, opportunities for massage therapists will likely grow exponentially. To specialize in pain management, however, massage therapists need to rethink how they define four distinct areas: 

1. Self-promotion, aka marketing, needs to reach beyond clients and target each pain management specialist on the “dream team.”

“I find that massage therapists don’t do enough to create a network of licensed professionals who can support their clients across the full spectrum of pain management. So, I make a point of introducing myself and our center to PCPs, surgeons, chiropractors, physical therapists and everyone in the pain management network,” explains Mary Biancalana, LMT, founder and owner of the Chicago Center for Myofascial Pain Relief. 

Biancalana typically initiates an introduction with a letter that explains her expertise in anatomy, kinesiology, massage therapy and trigger point therapy. Support materials include professional-level marketing tools, including a website and brochure. 

Her initial letter also includes an invitation for a center tour. “I’ve had doctors say, ‘You have 15 minutes.’ That’s enough time to show them maybe half of our space and explain the trigger point model. When I see interest, I ask to demonstrate with a complementary treatment—maybe on their trapezius muscles to relieve neck pain.”

The payoff is big, Biancalana concludes. “We collaborate with neurosurgeons who understand that not everybody needs neurosurgery, and that treating soft tissue can impact the mechanism of pain. Guess who they refer their patients to?” 

2. Communication style and language needs to be individualized for different pain management specialists.

The key to communication is presenting information that complements or adds to what the physician, chiropractor, or physical therapist knows—so it’s a discussion and not a lecture, explains Randy Clark, LMT, founder and president of the St. John-Clark Pain Treatment Center in Clearwater, FL. “When I work with a physician, I make it clear that I respect their knowledge of anatomy, but what I offer is something they don’t specialize in—which is how to manipulate a muscle to relieve pain. There’s no hierarchy here. It’s a team.” 

Biancalana offers an example of how she communicates with a physician who is most familiar with succinct medical records that report fast facts germane to the diagnosis. “Let’s say a doctor refers a patient who has chronic headaches. I would send a follow up report to the primary referral source documenting that I saw this referral on these five dates, treated the 13 key muscles that can contribute to headaches, and found that seven of these muscles impacted the patient’s headaches. After five treatments, the headaches dropped from a 7 out of 10 on the analogue pain scale to a 3.” 

Expanded networking efforts allow the massage therapist to guide clients to a far more individualized, multimodal treatment plan.

For example, Lashley saw a client suffering from jaw pain, and after several massage therapy sessions, she determined that a poorly fitted nightguard was the source of pain. “I reported my findings to the client’s dentist, who I’d worked with before, and asked the dentist to adjust the night guard. The dentist was actually very grateful for my note. Jaw muscles aren’t his area of expertise. So, together, between the adjustment and massage therapy, we resolved the client’s jaw pain.”  

3. Becoming part of a pain management network requires a deeper understanding of anatomy.

“An LMT certificate is important, but it does not prepare you to analyze and chart anatomical structure and interpret how the muscles contribute to complex conditions that cause pain,” Clark says. “For that, you need advanced anatomy classes.”

Lashley agrees. “In my experience, the average massage therapist coming out of school has a good basic knowledge of the muscles, but to read the notes we take at our pain center—the notes we share with physicians and surgeons in our network—you need higher-level anatomy training.” 

In addition to advanced education, expanded networking efforts, and vital research, Dr. Langevin brings up another concept that could potentially change what chronic pain management looks like in the not-so-distant future. It’s called transdisciplinary education, or interprofessional education, where students from complementary disciplines learn side by side. For example, massage therapists and physical therapists learn anatomy in the same classroom along with medical students. 

“We’re seeing more medical schools bring transdisciplinary education into their curriculum,” Dr. Langevin says. “This could really change how physicians and nurses interact with integrative therapists in their professional lives.”

4. Expanded networking efforts allow the massage therapist to guide clients to a far more individualized, multimodal treatment plan.

For example, Lashley saw a client suffering from jaw pain, and after several massage therapy sessions, she determined that a poorly fitted nightguard was the source of pain. “I reported my findings to the client’s dentist, who I’d worked with before, and asked the dentist to adjust the night guard. The dentist was actually very grateful for my note. Jaw muscles aren’t his area of expertise. So, together, between the adjustment and massage therapy, we resolved the client’s jaw pain.”

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