Massage, Endorphins, and Sacred Cows

From time to time this blog will focus on massage therapy research, and we’ll shine a light on some of the myths, or “sacred cows” we’ve been taught about its effects. First up: a claim we’ve been making for years, with little to support it.

It’s common practice to state that massage therapy increases endorphins. In our training, many of us were taught that massage flooded the body with endorphins, with positive effects on pain and well-being. Our websites, brochures, trade journals, and classrooms are heavy with this claim. We’ve repeated it many times. Rarely is it questioned.

A Trip to the 1980’s

But question it, we must. Unfortunately, the research on massage does not support this statement. I know of only two research studies on massage therapy and endorphins, both published in the 1980’s.

In the first, “Effect of massage on serum level of beta-endorphin and beta-lipotropin in healthy adults,”JA Day et al found no differences in the blood beta-endorphin levels between a group receiving a 30-minute back massage, and a control group that simply rested (abstract here). This was published in 1987, and I haven’t seen any follow-up to the study.

A couple of years later, another small study appeared. This one involved 12 volunteers, and researchers found a moderate increase in plasma beta-endorphins after a 30-minute session of connective tissue massage (abstract here).

This would seem to be good news, but a sample size of one dozen people is too tiny to support firm conclusions. Moreover, there was no control or comparison group, so there was no way to tell whether endorphins might increase naturally, with comparable fluctuations throughout the day.

Finally, the massage modality in this study is different from the usual massage strokes and pace of classical Swedish massage. The distinction in modalities is important: Even if this study did show strong results, I would not be able to claim the same effects from my standard Swedish fare.

Both of these are pilot studies, small test studies to see whether further research is warranted. The first shows no change, and the second suggests a change but with no control to establish whether the change might have happened without massage.

Time to Drop the Word “Prove.”

By themselves, these studies fall far short of proving massage increases blood endorphin levels. Nor do they prove that it doesn’t. Rarely does a single study prove anything. Two small studies do not deliver a conclusion. Instead, a body of research is needed to settle a question. So as of this writing, that body of work has yet to be built, and the question of massage and endorphins remains unanswered.

But still we’ve claimed massage increases endorphins, to the tune of about a quarter-million hits from googling “massage endorphins.” My own well-being would have suffered from trying to check them all, but a quick sampling showed most claimed massage increased endorphins. Hardly any cited research. The ones that did tracked back–wait for it–to these two tiny studies from the 1980’s. At the end of an afternoon on PubMed and Google, that’s all she wrote. Two small studies.

Time to drop the word “prove.”

The massage-endorphin question points out another pitfall in massage therapy, our tendency to confuse clinical and mechanistic effects.  While mechanistic effects might explain clinical effects, they are not the same thing.

Mixing up Mechanisms

Clinical effects are changes of clinical interest: changes in signs, symptoms, the ability to cope with disease, psychosocial effects of injury, and so on. A researcher looking at effects of massage on sleep, pain, anxiety, stress, function, and social behavior is looking at clinical effects.

Mechanistic effects are typically changes in physiological, biochemical and cellular parameters. These are the tiny things such as molecules or cell populations: the hormones, neurotransmitters, white blood cells, hemoglobin, and other stuff of the tissues, blood, and other body fluids. In class I call them the “juicy” outcomes. A researcher looking at endorphins, serotonin, epinephrine, dopamine, or lymphocytes is examining possible mechanistic effects of massage.

Clients rarely ask us for mechanistic results. When was the last time a client asked you for a boost in dopamine, a drop in cortisol, or a change in serotonin? Most clients just want to feel better. Clients typically want tangible clinical benefits.

Straightening out Our Claims about Massage

As for endorphins, for decades, we’ve understood that they are involved in well-being and pain relief. We’ve heard our clients’ reports of reduced pain, eased stress, or improved well-being. Then we’ve made a leap in logic, and attributed it to a bump in endorphins from massage.

It would be better to state, humbly, “We don’t really know the effect of massage on endorphins. There is only a little research, and it’s inconclusive. We need more research to establish whether different kinds of massage therapy increase, decrease, or have no effect on endorphins.” In dropping our endorphin claims, we give up very little–just a small, unfounded mechanistic claim.

Because in place of the pesky unanswered endorphin question, we can focus on the clinical. On what we do see and celebrate it. You have a client who reports less stress, or less pain after massage? Tell the story. Improved well-being, or quality of life? Tell the story. Fewer migraines? Tell the story.

Guard client confidences, of course. Be careful not to pass these off as researched results, of course. Recognize them as single stories–anecdotes–that might not reflect true cause-and-effect. Your apparently fantastic results with a handful of people might not be replicated by the MT down the street, nor shared by the general population. But observe away, and share your observations.

Some of your stories might already be reflected in good massage data. Others might wait years for a “yea” or “nay” from clinical research. But telling your stories is a start. Any one of them could be an important touchstone for further investigation, which can expand the body of knowledge about massage.

Write it Down

That story is most likely to become a touchstone if you write a case report to tell us about it. Your findings suggest the potential clinical effects of massage, and we need to hear about ’em.  (Ahem. Pretty please? The case report contest at MTF is now open! Cash prizes!)

As for the research, there are some strong findings on massage benefits, but it’s not about endorphins. Massage and depression. Massage and anxiety. Growing research on massage and pain. Focus on that. Stay tuned to this blog and we’ll bring in more of that good stuff.

As long as the mechanistic effects of massage are still being sorted out, we do better to point to clinical effects. Most clients want clinical effects from us, anyway: Few clients request endorphin boosts, many clients request pain relief and relaxation. By emphasizing the clinical effects, we’re on much more solid ground.

References

Day JA, Mason RR, Chesrown SE. Effect of massage on serum level of beta-endorphin and beta-lipotropin in healthy adults. Phys Ther. 1987 Jun;67(6):926-30. http://www.ncbi.nlm.nih.gov/pubmed/2954166.

Kaada B, Torsteinbo O. Increase of plasma beta-endorphins in connective tissue massage. Gen Pharmacol. 1989;20(4):487-9. http://www.ncbi.nlm.nih.gov/pubmed/2526775.