Massage FYI

Over the years I’ve had lots of conversations about massage therapy that ended with patients telling me “wow I never knew that” or “no one’s ever told me that”.

This page is a deep dive on a lot of my insider opinions about massage as a therapy and as a field of work. This is by no means required reading, but each topic is something I’m passionate about. Think of it as everything you never wanted to know about massage!

Feel free to skip and skim for what looks relevant to you.

Here are some facts I wish more people understood about massage (or at least massage as I want you to experience it!)

LMT means Licensed Massage Therapist, and you can verify anyone’s credential easily.

(In other states, the therapist may be called something else, depending on that state’s licensing structure. In WA, it’s LMT, but used to be known as LMP, for Practitioner instead of Therapist.)

Many consumers don’t know about the issues regarding licensed and unlicensed massage therapists (yes, licensure is an issue for LMTs as well as NDs). In WA state, your massage therapist is licensed to practice by the Department of Health. With that comes specific obligations. An active license shows that your therapist has had adequate training from an approved school, passed the MBLEx, and is maintaining their continuing education requirements.

The law also requires them to post their license number on all advertising materials. If you are in their place of business and want to know it, their license should either be conspicuously displayed or freely available for inspection on request. And if you want to double check they haven’t made up a number and their license is in good standing, you can look them up at any time.

Try it with my credential, MA60511096, at
(Select Credential Type MA, then the numbers, and don’t forget the anti-robot check at the bottom of the page. You can also search by name, but you’ll see there are a few other Rachel Frys in WA.)

Unfortunately, and especially in western Washington, there are many unlicensed massage therapy places and practitioners. You can usually guess which places they are by looking at the physical location, pictures used in advertising, or their listed services. Many times these “businesses” are fronts for human trafficking or other illegal services, but the police do not have the resources to go after each one. All I can do is warn my patients that unlicensed people performing massage have significantly increased potential to do harm.

Massage therapists will vary (but you should keep looking for the right one!)

Most massage schools will give their students a foundation of training in two techniques called Swedish massage and Deep Tissue massage. The training is also likely to include introductions to many other techniques, which the practitioner can pursue in greater depth after licensure.
As time goes on, the massage therapist will refine their technique in ways that incorporate other skills they like. They also find a groove of what body mechanics work best for using their unique body to perform the work. No two massage therapists will have exactly the same bodies and scope of experience, and as a result will always produce different massages. Even the same therapist can give different massages to the same person on different days. While that’s frustrating, it’s important for consumers to understand massage is as much an art form as it is a science.

When people expect one LMT to give them the exact same work as another LMT, they can end up disappointed. I tell people all the time that just because someone is a good therapist does not mean they are the right therapist for you. If you didn’t get the care you wanted (especially if you felt too sore after, but we’ll get into that next), keep looking! The right therapist is out there for you.

Deep Tissue does not have to mean deep pressure!

There’s a few things to unpack here.
First, there is a line between “therapeutically uncomfortable” and “not therapeutic, painful”, and for my sessions I can usually tell if that line has been crossed when my patient starts holding their breath or guarding. So many people have a “no pain, no gain” mentality, and I try hard to walk them back from it. Yes, working through knots or adhesions can be uncomfortable but still beneficial. However, if an area isn’t releasing, it’s time for a different tactic.

Sometimes that tactic is more frequent work! People come in with tension that has built up over years and expect it to go away in a single session. Unfortunately, that’s not how your body works. It will be much more tolerable and more beneficial if we do a couple shorter but more frequent sessions to work down into those problem areas.

A man wearing boxing gloves makes a pained face on receiving a hit to the right cheek from a boxing glove worn by an unseen person out of frame.
For the record: not therapeutic

Second, I want to address the people who keep asking for “more pressure”. Just like “no pain, no gain” isn’t really true, “deeper” does not mean better. If your goal (like mine for you) is to relieve the tension, restore mobility and function, and improve nerve conduction in an area, we should use any relevant and safe tool at our disposal. In some cases, it becomes unsafe for a therapist’s body mechanics (and longevity of their career) to apply deeper pressure. Sometimes, even with proper body mechanics, there are simply limitations in the physics.

Often, however, patients’ muscles are so locked up and patients are so out of touch with normal function of their muscles and nervous system, the deepest pressure is all they can feel as being therapeutic at all. This is where I often recommend a combination approach of deep tissue, heat, cupping, scraping, and stretching. A complex muscle problem requires a complex solution, not a sledgehammer.

Lastly, in contrast to Swedish massage, Deep Tissue for me is simply about intent. If Swedish is for relaxation, cohesion, and flow, Deep Tissue is about removing specific therapeutic obstacles. “Deep” means different things on different body types and different levels of dysfunction. You can accomplish Deep Tissue through various combinations of techniques if pressure levels are appropriate for each problem spot.

We cannot resolve years of tension in a single session. And if we try to, you’ll probably feel terrible after.

I mentioned it above, but it’s worth its own line. I know you and I both wish I could, but it’s simply not realistic. You leave a single session feeling at least somewhat better the day of. Then you tell me later that your problems “came back”. That’s because they never truly left. Truly unwinding problem areas to get to a maintenance level of care takes time.

With the pandemic, I saw a lot of people who hadn’t had massage in years, and they’d tell me they wanted deep tissue. I get that you want to feel better, but I can almost promise you if you receive full body deep tissue when you haven’t had any bodywork for a long time, you will feel like you have the flu for days after. Hint: that’s not therapeutic either! That’s being overworked. Let’s be committed to a pace where you can still function after our sessions and make incremental gains.

For what it’s worth, sometimes despite my best intentions, overwork still happens by accident. Maybe it seemed to both of us that your muscles were tolerating the work well, but if you feel too sore after and you tell me about it, it helps me know we need to back off a little on your next session to meet your muscles where they are at in their recovery.

Everything is connected. And without some tension you’d fall apart.

A spiderweb in close focus is covered in many dewdrops against a gradient black to yellow background.
Every connection is part of the structural integrity of the whole.

We are still discovering new things about the fascia system, which runs throughout and around every structure in the body. Your body is a 3D structure where no component exists in true isolation. Even if you’re targeting a certain muscle for training, it relies on a number of other muscles for support. The nervous system also has a funny way of making it difficult to pinpoint where some areas of pain are.

These are all reasons why when you tell me where it hurts, I don’t just work on that one spot. If you have low back pain, you can bet I’m at least checking your mid back and glutes, but probably also hamstrings and psoas. Similarly, for upper back or neck pain, we’re checking your shoulder muscles first. Then often your pecs (which are the oft-forgotten front of your shoulder girdle), and usually your axillae (armpit muscles!). This is often how we discover related areas; my patients tell me “I had no idea it hurt there until you touched it.”

Also, the goal of bodywork isn’t necessarily to have NO tension. Muscles are supposed to have a certain amount of tension. They support the body’s posture and keep you from being a puddle on the floor. I point out tension areas during session not to identify an enemy to be conquered; it’s my job to educate you about patterns you might not see. Tension may not even be present in the areas causing you pain. The goals of care are to create adequate support for your body, decrease distressing symptoms like pain, and provide adequate mobility for the things you want to accomplish.

The beef jerky analogy.

Image by Mark Valencia from Pixabay

Maybe you’re vegetarian and won’t understand this analogy, or maybe you and I have different opinions about beef jerky quality. We’ll have to agree to disagree, because here are my fighting words: dry, hard, stringy beef jerky is useless. I say this even knowing the definition (as seen in wikipedia and includes the fact that it is dried, dehydrated (literally reduced of its moisture) in order to preserve it. It’s like gnawing shoe leather, regardless of flavor. Better beef jerky, even if not as long-lived on the shelf, is moist and supple.

And even if we don’t want to acknowledge it, beef is muscle. Now we’re not cannibals, but you can probably see where I’m going with this. If you have tried to bend or manipulate an over-dry piece of jerky, it’s not going to be very flexible. Well guess what, the same is true of your living muscle tissue. Living muscle in your body needs to be moist and supple in order to be mobile and have good blood flow. Blood flow is important because muscles need oxygen to do their work. When they are done with their actions, the metabolites need to get flushed from the area (through blood or lymph). Tense muscles don’t get as much oxygen as they need, and they get restricted in flushing out metabolites. These contribute to soreness and achy-ness.

That is to say – hydrating before your massage session can make your work more effective. Hydrating AFTER your massage can help reduce soreness from us forcibly moving those metabolites into your circulation systems. With a few exceptions (like if you have kidney problems), I will always remind you to stay hydrated after your appointment.

You can (mostly) blame insurance companies for difficulty in getting covered care.

Massage therapy is a weird field. In WA state we are healthcare providers, so LMTs can accept health insurance plans. Unfortunately, there’s a catch, and everyone loses in the current system.

To be in network with an insurance plan, the LMT applies to be credentialed. The first problem is that most insurance panels are closed to independent massage therapists. A loophole to this currently is if you are in a group practice; you might get credentialed because others in the practice already are.

You might think this means the network is chock full of options for you. Instead, you’ll discover the frustrating fact that the insurance companies don’t audit their list of providers. Many of those listed may not be accepting new insurance patients (we’ll come back to this); but many may not be in practice at all anymore! The insurance company will say they have adequate coverage, but the reality falls starkly short.
Even if you can find a therapist on the list, they may not be accepting new insurance patients. Because they aren’t letting new therapists in, those who ARE credentialed are solidly booked.

A man in a business suit is seated at a patio table between two tall buildings with his laptop and coffee cup on the table. He looks skyward with his hands extended in front of him, slightly curled, expressing a look of frustration and distress.

More commonly, however, therapists simply don’t want to be credentialed with insurance. Here’s the sorry truth – insurance reimbursement for massage services sucks. Especially in an area like Seattle with high standard of living costs, most insurance reimbursements are well under what LMTs need to keep their practices running. Reimbursement rates haven’t risen in almost 20 years, and some have even decreased.

A therapist may take on many insurance patients as a matter of volume. However, this volume eventually destroys the career of many bodyworkers (I talk about this later). To actually make a living, it is much easier to have a cash-based practice. Everyone deserves to make more than needed to merely survive.

LMT employees taking insurance make tradeoffs to provide your covered care.

For you as a consumer, let me shed some light on the employee side of accepting insurance.

First, insurance pays for care deemed “medically necessary”. Medical necessity must be proven by a doctor writing a prescription for massage therapy. The prescription (rx) will include some specific diagnostic code naming a condition or symptom. It is out of scope of practice for an LMT to provide this code, even for symptoms.

If you have no medical necessity, the session falls under “wellness care”. You cannot get coverage for wellness care, or preventative care, or maintenance care. If you come in to the session saying you feel fine, that is not medically necessary and your claim can get denied. A claim denial can get your massage therapist in trouble; they may not get paid for your session, or worse, the insurance company many require them to pay back compensation they received.

Second, the LMT employee may not be making a great hourly rate because the business simply can’t afford to pay them more. The business gets the reimbursement amount for the service from insurance. That amount doesn’t just need to cover the LMT’s labor and supplies like lotion and laundry. Other staff are often involved, in scheduling this appointment and the next, and checking the patient in and out. You can see how this puts business owners in a bind when it adds up.

Full time for a massage therapist is not the same as an office worker.

As you can imagine, massage work is physically taxing. Each therapist will have a different threshold for how many 60-minute sessions they can do per day or per week. Massage school teaches the average lifespan for most therapists’ careers is only about 5 years. Usually, it ends because of burnout or injury. Unfortunately, many massage therapists feel forced into doing many sessions per week just to make ends meet.

There is no set standard for what qualifies a therapist as full time. The consensus among LMT colleagues is 20-25 table hours per week (which does not necessarily include room turnover and charting), but can go as high as 30-35 massages per week. Think about that. 20 massages over 5 days a week is 4 massages a day, which I think is about average. Some therapists work more days, or do more massages in a day. I’ve heard of some therapists doing 6-8 per day.

Not all of us can keep that pace, even with the best body mechanics or the best tools. I learned early on from pushing myself too hard that I do my best, consistent, safe-for-me work at no more than 3 sessions in a day. I actually prefer 2. My patients are always getting my best work. Luckily I have other skills where I don’t have to rely on the physical labor to make ends meet, but many LMTs are not so lucky.

A letterboard sign reading "Self Care Isn't Selfish"
For my own well-being, I learned I had to set boundaries on how much work I performed.

Tip your regular massage therapist, but not me.

With all these things in mind, I will say this without judgment: Many people using insurance don’t think about tipping their therapist. Odds are if your LMT is an employee, it helps them a lot.

Every massage therapist will probably have a different opinion on this, but here’s mine. “Never expected, always appreciated” is sometimes just not true. Many LMT employment situations are structured for LMTs to depend on tips as part of their regular compensation.

Especially when it comes to therapeutic care, in my opinion this is a problem in the industry. It creates a strange power dynamic in your therapeutic relationship that doesn’t belong there. A tip is intended as a bonus for a job well done, but has been warped by the system as a forced expectation. It is an industry-wide problem that isn’t solved by our personal feelings about the matter. As a consumer myself, I make a conscious decision when receiving services to acknowledge that as much as I am able, I tip my service providers, knowing they usually depend on it.

I am a naturopathic doctor performing massage in a cash-based practice; I am not beholden to insurance companies for compensation. As a solo business owner, I set my service prices where I feel their value lies without any hidden costs. I want my patients to know the price they pay for services with no surprises. (Services aren’t taxed in WA, so the advertised price is what you pay. Tax comes in on products, like supplements.)
As such, I don’t encourage tips for my massage services, but I do encourage you to tip your normal LMT.

Massage in the era of COVID

Remember when I said insurance companies were mostly to blame? While that does mostly apply to covered care, what many people don’t realize is that the pandemic has been pretty difficult for the massage community. Even before 2020, massage school enrollment has been dropping. Massage schools are closing; and those in practice continue to retire over time. With the pandemic, especially early on, it was hard to know what to do. How can you safely massage in a closed-ventilation room from less than 6 feet away? Some therapists decided to just stop working until we got a handle on the situation, even with masking.
Then, after vaccines and medications became available, many therapists never returned to work due to risk. Some were dealing with pre-existing conditions of their own, or they worked with immune compromised populations. Some had at risk family members. They left for different fields of work entirely.

Thus, an already decreasing population of available therapists became even smaller. If you’ve noticed it’s been difficult to find room on ANY therapist’s schedule, this is a contributing factor.