What Could Possibly Go Wrong With Massage?

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Massage Therapy Side Effects

What could possibly go wrong with massage? The risks and side effects of massage therapy are usually mild, but “deep tissue” massage can cause trouble

SUMMARY

Massage therapy is very safe, but nothing’s perfect. Strong, deep tissue massage causes the most trouble, of course. It may aggravate problems, instead of helping. Some chronic pain patients may be disastrously traumatized by intense massage

(what I call a “sensory injury”)

. Occasionally it causes new physical injuries, usually just minor bruises and nerve lesions, but sometimes worse: there’s a small but serious risk of spinal injury or stroke with any neck manipulation.

Patients often feel sore and a bit oogy after massage, a phenomenon known as post-massage soreness and malaise. Although often rationalized by massage therapists as a healing crisis or the effects of detoxifying, it’s probably just widespread minor muscle crush injury

(rhabdomyolysis)

.

Finally, as with all alternative medicine, sometimes massage therapy is a harmful

(and expensive)

distraction from more appropriate care.

full article 2750 words

People think of massage therapy as a “safe” therapy, and of course

it mostly is

. But things

can

go wrong, or at least a bit sour. While serious side effects in massage therapy are extremely rare,

minor

side effects are downright common. A 2007 survey of 100 massage patients

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found that 10% of 100 patients receiving massage therapy reported “some minor discomfort” in the day following treatment. This would mainly be a familiar slight soreness that is common after a massage, known as “post-massage soreness and malaise” (

PMSM

) — and I’m surprised

only

10% reported it. The massages they were getting must have been quite gentle.

2

Interestingly, 23% reported unexpected benefits that had nothing to do with aches or pains. (Benefits for musculoskeletal problems were not documented.)

This study is underpowered; it cannot and does not rule out rare and/or serious side effects of massage therapy, which do exist. You could probably do several studies of 100 patients without encountering a single nasty situation. But what if you surveyed 1,000 patients? Or 10,0000? Massage is not completely safe — what is? — and other adverse effects would almost certainly turn up in a big enough survey. Nevertheless, according to one of alternative medicine’s most vigorous critics,

Dr. Edzard Ernst

, “Serious adverse events are probably true rarities.”

3

And yet, reviewing the literature again in 2013, Ernst and Posadzki found at least 18 reported examples of “moderately severe” reactions to normal massage, especially of the neck.

4

When massage goes bad

So what could possibly go wrong? Massage can…

  • directly cause new injuries, mostly bruises and nerve lesions (mostly quite minor, but not all)
  • aggravate existing injuries and chronic pain problems
  • distract patients from more appropriate care
  • mildly stress the nervous system
  • probably cause rhabdomyolysis (too much protein released into the bloodstream from crushed muscle)

And don’t forget, of course, that pointlessly draining your wallet is another kind of pain. If someone spends $5,000 on massage therapy that has only a minor therapeutic effect, or none at all, is that an “injury”? It’s an insult, at the least!

In my decade (2000–2010) as a massage therapist, I met

many

patients who had been harmed by massage therapy to some degree — fortunately, mostly just expensive disappointments and minor backfires, but quite a few more serious cases too.

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Sensory injury

A painful, alarming sensory experience can actually

dial up pain sensitivity

— even long term.

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Furthermore, vulnerability to this awful phenomenon is much more common and significant in desperate patients who already have chronic pain — so they seek and tolerate intense therapy.

The experience of pain is affected by many factors, including emotional and psychological ones. People in chronic pain usually experience some degree of pain neurology dysfunction, and a breakdown of the relationship between how bad things feel and how much is really wrong. That breakdown can be seriously worsened by threatening sensations. Thus, people experiencing pain system dysfunction can have minor and major setbacks in response to excessively painful massage.

One of my readers suffered this kind of disaster. She was injured by “fascial release” therapy, a style which is often too intense and may focus on treating connective tissues to the exclusion of considering the patient’s comfort and nervous system.

I may have been too aggressive with a few patients over the years. I never did serious harm this way as far as I know, but I’m sure that I occasionally did more harm than good. This failure was due entirely to my ignorance of pain science: despite being an unusually well educated massage therapist, I simply did not know that an intense massage could change pain sensitivity itself. Does

your

therapist?

~ 11,000 words


Pain is Weird
Pain science reveals a volatile, misleading sensation that is often more than just a symptom, and sometimes worse than whatever started it

~ 4,750 words


The Pressure Question in Massage Therapy
What’s the right amount of pressure to apply to muscles in massage therapy and self-massage?

Poisoned by massage

People often feel sore and a bit “oogy” after strong massage, the phenomenon of post-massage soreness and malaise (PMSM). It’s routinely dismissed and rationalized by massage therapists as a necessary evil, a “healing crisis,” the effect of detoxification. That’s all bullshit. At best, it could just be a form of mild disorientation, basically feeling “weird” after an unusual and intense sensory experience. But it’s probably more biological, and actually the

opposite

of detoxification: a light

poisoning.

Excessive pressure can probably cause rhabdomyolysis (“rhabdo”): poisoning by proteins liberated from injured muscle, known as a “muscle crush” injury. It would usually be mild with massage, but not necessarily.

For example: an 88-year old man collapsed the day after an unusually strong 2-hour session of massage therapy.

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He had too much myoglobin in his blood, and it was clogging his kidneys and generally making him feel rotten. It’s not a sure thing that his condition was cause by the massage — but it is quite likely. It is almost certainly a perfect example of one of those rare but serious complications of massage. Another case study comes up below.

True rhabdo is a medical emergency in which the kidneys are poisoned by myoglobin from muscle crush injuries. But many physical and metabolic stresses cause milder rhabdo-like states — even just intense exercise, and probably massage as well. There are many well-documented cases of exertional or “white collar” rhabdo, and there is a strong similarity between PMSM and ordinary exercise soreness. A rhabdo cocktail of waste metabolites and by-products of tissue damage is probably why we feel a bit cruddy after all biological stresses and traumas — including massage, sometimes.

PMSM is just an unavoidable mild side effect of strong massage. And for a few more vulnerable patients, it could actually be a little dangerous.

~ 5,000 words


Poisoned by Massage
Rather than being DE-toxifying, deep tissue massage can probably cause a slightly toxic situation in the body

Getting on your nerves

Nerves aren’t nearly as vulnerable to pressure as people generally think — most of them can actually take quite a licking and keep on ticking without a single symptom — but they aren’t invulnerable. Push hard enough in the wrong place, and you can injure a nerve, of course. In a 2017 incident, a woman’s radial nerve was crushed by an aggressive massage in her upper, inner arm. It’s rare, but it happens.

8

And I once caused such a nerve injury myself: it was a minor injury, but it did —

augh

— result in weeks of aggravating discomfort for my client.

The

Archives of Physical Medicine & Rehabilitation

reported a similar spinal accesory nerve injury: “a rare and illustrative case of spinal accesory neuropathy associated with deep tissue massage leading to scapular winging [the shoulder blade sticking out] and droopy shoulder as a result of weakness of the trapezius muscle.”

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~ 1,600 words


Can Massage Damage Nerves?
It is possible, but hard to do, rare, and the damage is usually minor

The neck is a vulnerable spot

The neck is not an especially fragile structure, but it is in

some

people, and there’s always a danger — with any kind of neck manipulation — of disastrously messing with a critical vulnerability that’s lurking in the spine. This can lead to two main kinds of rare but truly dangerous side effects of massage: spinal cord injury associated with instability of the upper cervical spine, or stroke caused by tearing of the vertebral arteries. I’ve had personal experience with three cases:


  1. What happened to my barber

    — either a brain stem injury or mini-stroke caused by careless massage of a vulnerable neck.
  2. One of my own patients was injured the same way by another therapist. She vomited and retched for hours afterwards: the nasty effects of brain stem impingement, or ripping of an artery going to the brain.
  3. I came somewhat close to inflicting the same fate on another patient of mine early in my career, but I’m proud to say that I spotted the warning signs and avoided disaster.

These problems aren’t common, but that’s three in my own relatively short (10-year) career, so it’s hardly unheard of.

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And then there are examples I had no involvement in…

A weird case of brain artery damage (extracranial internal cartoid artery dissection, specifically) was reported in 2004 by the

Southern Medical Journal

: a 38-year-old woman gave herself a stroke by using a vibrating massage tool for long and too hard on her neck.

11

Obviously such an incident has little to do with professional massage. Nevertheless, it demonstrates that the arteries of the neck are a little bit fragile — and I have no doubt that there are poorly trained or incompetent therapists out there would might get carelessly exuberant in this region, while trying to treat the scalenes: see

Massage Therapy for Neck Pain, Chest Pain, Arm Pain, and Upper Back Pain

.

~ 3,000 words


What Happened To My Barber?
Either atlantoaxial instability or vertebrobasilar insufficiency causes severe dizziness and vomiting after massage therapy, with lessons for health care consumers

Miscellaneous cases studies and tales of massage woe

A weird, extreme case study paper tells the horror story of one person’s awful experience with a severe reaction to (apparently) infrared heat and massage therapy.

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The trouble started after several treatments. His neck and arms were swollen, the pain became “unbearable,” and his “serum muscle enzymes were increased” — which means some degree of rhabdo, which implicates the massage itself as a significant mechanism of injury. Massage is not likely to blame for the incident, though — it was probably interacting with some unidentified vulnerability in the patient, such as a muscle disease or a complication caused by a medication. Clearly massage and heat alone do not normally cause such severe side effects! Nevertheless, the potential for awful interactions does exist, and this is a good example of it.

“Alternative therapies may have serious complications, and patients usually do not report them unless asked specifically,” the authors point out.


Headaches

are an extremely unpredictable and complicated category of problems with countless possible causes, and they can be seriously aggravated by massage. I’ve heard many such stories over the years. One of the worst came from one of my own massage therapists, who suffered “the worst migraine of my life,” which started during a relatively innocuous neck and head massage. “I knew it was happening. I could feel it getting worse as she worked. I still can’t believe I didn’t stop the treatment.”

Stretching injuries.

Stretch is sometimes applied to patients by massage therapists, sometimes very strongly, and of course they routinely recommend it. Although mostly safe, obviously you can overdo it. I know this one from personal experience:

Stretching Injury

.

Fractures.

I am one-degree of separation from a patient whose

femur

(the big leg bone!) was fractured by a massage. It was a weak and vulnerable femur to a modest degree … but still, wow! It’s the only fracture I’ve ever heard of personally, but I bet there are a few other examples out there.

Massage can dislodge blood clots

, which can then get trapped in the lungs or brain or other tissues, a potentially deadly complication. This would likely only occur with vigorous and careless massage of higher risk patients, but there are a few published case reports,

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14


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and it’s probably an under-reported complication.

Dizziness versus vertigo.

What’s the difference? Dizziness is the feeling of lightheadedness and unsteady, very familiar from “head rushes,” whereas vertigo is the more exotic sesnation with a

rotational

element: if you have the spins, that’s vertigo.

Dizziness and vertigo attacks.

These are classic non-specific symptoms that are easily triggered in many people, especially by massage for some reason,

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and just because many people are vulnerable to them for all kinds of reasons. There are potentially serious causes of dizziness/vertigo during a massage (see above), but there are probably many less worrisome cases as well. For instance, a reader told me this story:

I have

Meniere’s disease

. A month ago I had surgery: a surgeon cut my left ear “balance nerve” [

vestibular nerve section

] so it couldn’t send screwy signals to brain anymore. Post-surgery imbalance is expected for a few months as the brain adjusts, but a “vertigo attack” is supposed to be a thing of the past.

I went and had a two hour “deep tissue” massage. Near the end the room started to slowly rotate on me: the beginning of a vertigo attack! Do you think the massage could have caused this episode?

A good question without a good answer. Meniere’s is a peculiar disease, and the results of such a surgery are probably erratic and imperfect. I have no doubt a strong massage could trigger a vertigo attack in such a patient simply because

practically anything can

, including just stress, and a massage like that is a large dose of novel sensations and biological challenges (read: stress) — lots of potential triggers for Meniere’s, never mind in someone who got their vestibular nerve pruned just a month ago!

Lessons for professionals and patients

These are rare but real incidents. Healthy people are unlikely to be injured by massage. Most of dangers are related to undetected vulnerabilities, and they emphasize the importance of alternative health professionals being trained to spot the scary stuff. The measure of a health professional’s competence is not what they do with relatively healthy patients, but whether they have the training and humility to realize when they are on thin ice.

Manual therapists need to know

that the most important part of their job is the smart management high-risk situations that they may see only a handful of times in their entire career. It’s like being on guard duty: 99.9% of the time, nothing bad happens. But how do you handle a curve ball when it finally comes?

Consumers need to know

that cocky, overconfident therapists who trash-talk “mainstream” health care are all-too-likely to be ignorant of critical warning signs, or dismissive of them.

The skeptical salamander

thinks these therapists shouldn’t be allowed to touch anyone. See

Missing Serious Symptoms

.

About Paul Ingraham

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

I am a science writer, former massage therapist, and I was the assistant editor at

ScienceBasedMedicine.org

for several years. I have had my share of injuries and pain challenges as a runner and

ultimate

player. My wife and I live in downtown Vancouver, Canada. See my

full bio and qualifications

, or my blog,

Writerly


. You might run into me on

Facebook

or

Twitter

.

Notes

This is is a syndicated post. Read the original at www.painscience.com

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