Massage for chronic pain: where it fits in a plan

It is more common in older adults, military veterans and people in rural areas. NCCIH notes that chronic pain rises with age, partly because conditions such as osteoarthritis become more common, and that national survey data show both general and severe pain are more common among veterans than nonveterans. Chronic pain is also more common in rural areas than in cities.

Rates vary by race and Hispanic origin too: an analysis of 2010–2017 survey data found the highest rate among non-Hispanic American Indian and Alaska Native respondents and the lowest among non-Hispanic Asian respondents. Among people with a diagnosis, low-back pain and osteoarthritis are the most common, followed by rheumatoid arthritis, migraine, carpal tunnel syndrome and fibromyalgia. Some chronic pain comes from the nervous system itself, which clinicians call neuropathic pain, and sometimes no cause is found.

Chronic pain often comes with disturbed sleep, restricted movement, anxiety and depression, so a useful plan has to address more than the ache.

A complementary approach is used alongside conventional medical care; an alternative approach is used instead of it. Massage belongs in the first group. NCCIH's rule for all of these methods: don't use an unproven product or practice to postpone seeing a clinician about your pain.

NCCIH has also replaced its older label, "mind and body practices", with three groups sorted by how the therapy is delivered: psychological approaches such as meditation and music therapy; physical approaches such as acupuncture, massage and spinal manipulation; and combined approaches such as yoga and tai chi.

It shows small benefits, mostly short-term, that depend on the condition. The NCCIH evidence summary breaks it down by the kind of pain.

Several reviews found only weak evidence of benefit. The Agency for Healthcare Research and Quality reviewed 20 studies in 2016 and found massage helped chronic low-back pain, on low-strength evidence, and a 2015 Cochrane review found short-term relief with no established long-term effect. The American College of Physicians' 2017 guideline lists massage for acute and subacute low-back pain and leaves it off the chronic list.

This is the clearest signal, and it still fades. A 2013 review of 12 studies (757 participants) found massage beat inactive therapies for neck and shoulder pain but did no better than other active treatments, with only a short-term benefit for the shoulder. A 2014 trial of 228 people with chronic neck pain found that sessions of 60 minutes given two or three times a week worked better than shorter or less frequent ones.

A 2017 review of 7 trials (352 participants) found low-to-moderate quality evidence that massage reduced pain and improved function, mostly in knee osteoarthritis. The American College of Rheumatology and the Arthritis Foundation still conditionally recommend against massage for hip or knee osteoarthritis, citing weaknesses in the evidence. Both conclusions draw on the same small pool of studies, which suggests any effect is small.

A 2014 review of 9 studies (404 participants) found massage improved pain, anxiety and depression only when it continued for at least 5 weeks, and it had no effect on sleep disturbance. A single session falls well short of the course those studies tested.

NCCIH describes the risk of harm from massage as low. Rare serious problems, including a blood clot, a nerve injury or a bone fracture, have been reported, often with vigorous techniques such as deep-tissue work or in people already at higher risk of injury.

Acupuncture, tai chi and yoga have sturdier records for specific conditions. A large analysis of individual patient data found acupuncture more effective than both no treatment and sham acupuncture for back and neck pain, with a wider gap over no treatment than over sham. There is moderate-quality evidence that it reduces migraine frequency, and in studies against migraine drugs, people getting acupuncture were much less likely to drop out because of side effects. A 2017 review found that acupuncture, yoga, relaxation techniques, tai chi, massage and spinal manipulation may all have some benefit for chronic pain, but only acupuncture had evidence that it could reduce a patient's need for opioids.

Tai chi carries the strongest guideline language. The American College of Rheumatology and the Arthritis Foundation strongly recommend it for knee or hip osteoarthritis, after studies found improvements in pain, stiffness, balance and physical function, and the 2017 ACP guideline lists it for chronic low-back pain. Yoga helped low-back pain in both the short term (1 to just under 6 months) and the intermediate term (6 to just under 12 months), with effects similar to other exercise; the ACP lists it for chronic but not acute low-back pain.

For chronic low-back pain the ACP guideline also includes mindfulness-based stress reduction as an option, and suggests progressive muscle relaxation and biofeedback as first steps. Studies found mindfulness-based interventions and cognitive behavioral therapy (CBT) both lowered pain intensity and improved function, with no important difference between them, and CBT remains the prevailing psychological treatment for chronic pain.

The CDC's 2022 opioid prescribing guideline ties this together: several nondrug treatments improve chronic pain and function "with small to moderate effects in specific pain conditions" and "are not associated with serious harms." The guideline recommends making full use of nondrug and non-opioid treatments where appropriate.

Glucosamine, chondroitin, fish oil and vitamin D for osteoarthritis, along with Reiki and static magnets. The rheumatology guideline strongly recommends against glucosamine for the hand, hip or knee because the studies with the lowest risk of bias show it works no better than placebo, and it advises against chondroitin and combined glucosamine-chondroitin products for the hip or knee. It conditionally recommends against fish oil and vitamin D for osteoarthritis. There is not enough high-quality research to say whether Reiki relieves pain, and static magnets, sold in bracelets and shoe insoles, have no conclusive evidence behind them for any type of pain.

Cannabis products and hypnosis sit in between. Short-term studies suggest some formulations containing THC and CBD may reduce chronic pain, with side effects such as dizziness and sleepiness, and little is known about long-term use. Hypnosis may help, but the studies that found a benefit involved at least 8 sessions.

Plan it with the people treating you and expect a small benefit. The better-supported complementary approaches, massage included, tend to deliver the small to moderate, often short-term effects the CDC described, as one part of a plan that still includes conventional care. A small, low-risk benefit that adds to other treatment can be worth having when you know that is what you are paying for.

NCCIH's practical advice comes down to a few steps.