Is Massage Nature's Sleep Aid?


In a world where sleep has become such a precious commodity, could the prescription for better slumber be touch instead of a tablet?

Rebekah Delling, LMT, thinks so. When she was a girl, she suffered from an undiagnosed anxiety disorder that routinely kept her up at night. She’s been interested in sleep science ever since.

“Sleep is something I’ve always had an issue with,” says Delling, owner of the Hampton Holistic Center in Ross Township, Pennsylvania. “Not only did I have a lot of anxiety, but I’m also a night owl. I wasn’t sleepy at 9 or 10 o’clock. I was sleepy at 1 o’clock. So I’d have a lot of trouble falling asleep. I’d just lie there, and my anxiety would kick in.”

By treating her anxiety and improving her sleep hygiene, Delling eventually was able to resolve her own sleep issues. Because she wanted to help others resolve theirs, however, five years ago she decided to make sleep optimization the primary focus of her massage practice.

“I believe that sleep is the next big health issue, and that massage is a natural complement to sleep,” Delling says. “People who don’t necessarily have a sleep disorder tell me, ‘I’m really noticing a lot of benefits from massage. I’m even sleeping better.’ I hear it all the time, so it makes sense to me.”

From snoring clients to post-massage testimonials, anecdotal evidence abounds. But does massage therapy have an actual, demonstrable impact on sleep? Although answers remain ambiguous, both physicians and massage therapists are asking the question. And for some people, at least, that means the massage table could be the next best place to search for missing Zs.

Sleep Setbacks

The American Academy of Sleep Medicine (AASM) recommends sleeping at least seven hours per night.1 Unfortunately, more than one-third of Americans fail to do so, according to the U.S. Centers for Disease Control and Prevention (CDC), which says inadequate sleep is associated with an increased risk of mental distress, as well as numerous chronic health conditions, including obesity, diabetes, high blood pressure, heart disease and stroke.2

Sleep isn’t just nice, then. It’s a necessity. “Sleep is extremely important,” says David Leopold, M.D., medical director for Hackensack Meridian Integrative Health & Medicine, the integrative medicine practice at Hackensack Meridian Health, New Jersey’s largest health care network. “Sleep is the time when our body is repairing itself; if you’re not getting enough deep sleep, then you’re compromising your ability to repair damage that’s been done to your body.”

According to Leopold, sleep deprivation also can interfere with memory, impair immune function, and interrupt the body’s production and regulation of hormones and neurotransmitters. “If you’re not sleeping, you’re throwing your whole physiology off,” he continues. “It’s almost impossible to be a healthy individual if you’re not getting good, restful sleep.”

Of course, everyone experiences sleep disruption at some point. When sleeplessness lasts for longer than a few days, however, what began as a sleep disturbance instead becomes a sleep disorder.

“If it keeps happening every night for more than three weeks or a month, you’ve moved away from a temporary, roiling turbulence into more of a chronic problem,” explains Gandis Mažeika, M.D., founder of Sound Sleep Health, a sleep medicine practice based in Kirkland, Washington.

According to Mažeika, sleep disorders can be rooted in both psychology and physiology. Take the most common sleep disorder—insomnia. A catch-all term that describes the inability to initiate or maintain sleep, it could have mental underpinnings—depression or anxiety, for example—or physical ones, such as medication, substance abuse or a chronic illness like diabetes, arthritis, cancer or heart disease.3

Other common sleep disorders include:

  • Obstructive sleep apnea, wherein someone momentarily stops breathing in their sleep due to causes such as obesity, narrowed airways or nasal congestion
  • Restless leg syndrome (RLS), wherein a dopamine imbalance is believed to make people feel a “creeping” sensation in their legs that can only be relieved with movement
  • Narcolepsy, wherein a person for unknown reasons feels sudden daytime drowsiness that often manifests along with sudden muscle weakness.

Treatment can vary depending on the disorder and its underlying cause. Options might include medication, including sedatives like Ambien; supplements, such as melatonin; cognitive behavior therapy, which helps individuals control or eliminate the negative thoughts and actions that keep them awake; and, for obstructive sleep apnea, a continuous positive airway pressure (CPAP) machine that uses air pressure to keep airways open during sleep.

Although prescription sleep medication can be helpful for short-term sleep fragmentation, it can also have significant negative side effects. “That includes basic things like falling and daytime sedation to—for reasons we don’t fully understand yet—increased rates of death and other types of disease, including cancer and dementia,” says Leopold, who therefore prefers integrative therapies whenever possible—including massage. “I think massage can be a very valuable part of a comprehensive care plan.”

Pinpointing Pain

Whether someone is experiencing temporary or chronic sleeplessness, the best way to assess whether massage might help is to determine its underlying cause—for example, pain. “Massage is hugely helpful at relieving pain and discomfort. It’s very anti-inflammatory,” reports Mažeika, who says musculoskeletal pain is especially common among athletes with sports injuries as well as aging people with arthritis and other inflammatory conditions.

One way that massage might help pain is by increasing circulation and lymphatic drainage. For example, a 2017 study in the Journal of Manipulative and Physiological Therapeutics found that massage—specifically, manual lymphatic drainage (MLD)—can promote shortterm blood flow.MLD also has been found to increase pain threshold and pain tolerance in healthy individuals,5 and to improve pain, tightness and heaviness sensations in people with breast cancer-related lymphedema.6

“When the body’s in pain, it will often lock down an area. The ligaments and tendons around the area will have a reduced ability to stretch, and that isolates the area. One of the things those areas really need is increased blood flow, but what you actually end up getting is ischemia, which propagates the problem,” Leopold explains. “Massage forces blood flow into the area and reduces ischemia.”

Mažeika elaborates: “People carry stress in certain parts of their body, and massage works wonders to help undo that stress … For example, there are counter-strain techniques that are designed to reduce spasm around connective tissue, which can cause subtle rearrangements in circulation or nervous system activity that impact not just pain, but also range of motion and lymphatic drainage. In fact, if you have limited lymphatic drainage in a limb, a massage that’s dedicated to improving lymphatic flow will help edema in that limb and the deep ache that’s often associated with it.”

Clients tell Delling all the time that a sore back, neck or knee kept them awake at night. “Insomnia is usually a secondary symptom of something else—including pain,” she says. “If you can relieve the pain, you can alleviate the sleep issue.”

Stroking Away Stress

But pain is just one potential cause of sleeplessness. Another is stress. “Most people I’m seeing for sleep issues suffer from stress-induced insomnia,” reports Leopold, who says the key to combating stress is toning down the sympathetic nervous system that prepares the body for activity and activating the parasympathetic nervous system that prepares it for rest. “Most of us are constantly in fight or flight, which is our sympathetic nervous system. That’s fine when you need to run from a tiger, but it’s not great when you want to calm down and go to sleep. When your body loses the ability to enter a restful state, you have to retrain it to bring the parasympathetic nervous system back online.”

Whether massage can seduce the body into a parasympathetic state is unclear. On the one hand, there’s research like a 2009 study in the International Journal of Neuroscience, which examined the impact of massage on heart rate and concluded that moderate-pressure massage stimulated “a shift from sympathetic to parasympathetic activity.”7 A 2012 study in the Journal of Alternative and Complementary Medicine likewise showed that twice-weekly massage for five weeks increased neurotransmitters that stimulate parasympathetic activity, like oxytocin, and decreased neurotransmitters that inhibit it, like the stress hormone cortisol.8

On the other hand, there also is research such as a 2010 metaanalysis published in the Journal of Bodywork and Movement Therapies. Based on a comprehensive review of existing literature, it concluded that massage therapy has “wellestablished … beneficial effects on anxiety, depression and pain,” but that its effect on cortisol is “generally very small.”9

“There isn’t a lot of hard evidence [that massage stimulates the parasympathetic nervous system] because studies of that nature are very complicated and very invasive,” Leopold says. “What we do know is that any time you put the body into a relaxed state, there is a large cascade of ‘relaxation hormones’ that sets a better stage for sleep. And massage clearly is shown to have relaxing properties.”

Fascia—the sheath of continuous connective tissue that covers internal muscles and organs—may play a role, according to Dan Williams, D.O., an osteopathic physician based in Carmel, Indiana.

In fact, studies have shown that fascia is rife with sympathetic nerve endings,10 and that myofascial release may reduce anxiety.11 “Fascia absolutely is an inroad by which a massage therapist can influence the sleep cycle of their client,” Williams says. “There’s still a lot we don’t know, but once you understand that fascia exists—that it’s a living, breathing structure that gives feedback to the nervous system—you can start to conceptualize how fascial manipulation might have a positive physiological impact.”

Although evidence is scant, some researchers also believe that pressure can produce a parasympathetic response. A 2015 study in the American Journal of Occupational Therapy, for example, found that wearing a weighted vest for even short periods reduced sympathetic arousal and increased parasympathetic arousal.12 A 2009 study in the Journal of Physiological Sciences found that pressure stimulus applied over trigger points also enhances the parasympathetic nervous system.13 Proponents further point to the long-held practices of swaddling and rocking infants, which received support in a 2019 study published by the journal PLOS ONE; in it, Dutch researchers concluded that swaddling and movement promptly produced a physiological calming response in fussy infants.14

Adults are not infants, but Delling has observed positive responses in clients by leveraging the same principles of pressure and movement. “I take a lot of techniques from shiatsu and acupressure,” she says. “For sleep purposes, my focus is … on the deep, rhythmic pressure and rocking.”

Putting Sleep Problems to Bed?

When it comes to the physiological connections between massage and sleep, the jury is still out in terms of definitive research. While the jurors deliberate, however, massage therapists nevertheless can help facilitate better sleep—even if their actions aren’t yet proven to directly induce it.

“Data on massage and whether it helps with sleep is mixed, but when you look at the risk-to-benefit ratio, there really isn’t much risk in trying it, except what you risk in time and money,” Leopold says.

Delling agrees. “Putting aside for a moment deep, rigorous scientific studies, which are definitely important, just the fact that somebody is taking time out of their day to lie quietly on a table is huge. You’re resting your mind, you’re resting your body and you’re being touched by another human being … Regardless of what’s happening physiologically, that’s relaxing, and you can’t sleep if you’re not relaxed.”


8 Ways to Make Your Practice "Sleep-Ready"

  1. Scrutinize clients' sleep habits: A thorough intake form is the foundation of a successful sleep massage, according to Rebekah Delling, LMT, owner of the Hampton Holistic Center in Ross Township, Pennsylvania. “The first thing I do is a sleep assessment to learn about clients’ sleep habits,” explains Delling, who asks about everything from sleep schedule to nutrition so she can tailor her approach to clients’ individual needs.
  2. Diversify your touch toolbox: Every client is unique, and so is every sleep problem. Massage therapists who wish to help clients with sleep issues must therefore be trained in myriad modalities. “The key is being able to read your clients,” says Angela LaBorde, LMT, owner of Sacred Fire Healing Arts in Colorado Springs, Colorado. “That’s why I’m a huge proponent of knowing a wide variety of skills and techniques and being able to apply them in the moment based on what a particular person needs.”
  3. Tailor your techniques to the time of day: In her sleep-centered practice, Sandy Saldano, LMT, alters her approach based on time of day. “A massage can be energizing. So if somebody is not sleeping and they’re super tired, they might come in early in the day for a massage that uses more vigorous techniques—more percussion and kneading, for example,” says Saldano, president of Therapeutic Kneads in Highland Park, Illinois. “If someone comes in the evening, I’ll use more effleurage and deep-tissue techniques—something slower-paced that helps the body relax and wind down.”
  4. Consider complementary services: Massage therapists can help both their clients and their businesses by offering related products and services. In addition to massage, for example, Saldano offers pillow sales and consultations. “A lot of times, people have headaches, neck pain or back pain because of what they’re sleeping on, so we guide them through what they can do at home to bolster their body,” she says. “We look at their neck width, neck height, sleeping position—there are a lot of variables, and we look at all of them in order to help them choose a pillow that’s supportive. If they’re waking up in pain or discomfort, that can make a huge difference.”
  5. Set realistic expectations: Massage may help with sleep issues, but it isn’t magic. “People think they’re supposed to feel something different after one massage, but it’s something you have to do on a regular basis to see a cumulative effect,” Saldano says. “It’s like exercise; you can’t walk out of the gym feeling buff in one session.”
  6. Emphasize good sleep hygiene: Good sleep hygiene is essential, according to Delling, who offers sleep “coaching” alongside her massages. “I talk about things like the sleep environmen—your bedroom should be cool, quiet and dark—and what you do before bed,” she says. “For example, you shouldn’t be watching TV or checking Facebook before bed because the blue light from screens can disrupt the body’s natural melatonin production.”
  7. Grow your network: Sleep disorders are serious medical issues that demand serious medical attention. Massage therapists therefore have an opportunity—and a responsibility—to make referrals to physicians, psychologists and other professionals when necessary. “It’s not always what you do with your hands that helps,” Saldano says.
  8. Offer a restful envioronment: A restful environment is as critical to a good massage as it is to good sleep, according to LaBorde, who says massages should take place in a space that’s comfortable and quiet. “Create a meditative space and encourage your clients to have an internal focus,” she advises. “That doesn’t mean they can’t speak, but if they’re talking about work and other things going on in their life, try to bring them back into the moment and what’s going on with their body.”

Related Resource

Client Outreach: Research has show that massage therapy can help improve mood and reset circadian rhythms, which can lead to better sleep and more energy.


References

1. Watson NF, et al. Recommended amount of sleep for a healthy adult: a joint consensus statement of the American Academy of Sleep Medicine and Sleep Research Society. Journal of Clinical Sleep Medicine. 2015. http://jcsm.aasm.org/ViewAbstract.aspx?pid=30048.

2. 1 in 3 adults don’t get enough sleep. Centers for Disease Control and Prevention. 2016. https://www.cdc.gov/media/releases/2016/p0215-enough-sleep.html.

3. Insomnia. Mayo Clinic. https://www.mayoclinic.org/diseasesconditions/insomnia/symptoms-causes/syc-20355167.

4. Guerero RM, et al. "Manual lymphatic drainage in blood circulation of upper limb with lymphedema after breast cancer surgery." Journal of Manipulative and Physiological Therapeutics. 2017. https://www.ncbi.nlm.nih.gov/pubmed/28395985.

5. Keser I, Esmer M. "Does manual lymphatic drainage have any effect on pain threshold and tolerance of different body parts?" Lymphatic Research and Biology. 2019. https://www.ncbi.nlm.nih.gov/pubmed/31329499.

6. Sanal-Toprak C, et al. "The efficacy of intermittent pneumatic compression as a substitute for manual lymphatic drainage in complete decongestive therapy in the treatment of breast cancer related lymphedema." Lymphology. 2019. https://www.ncbi.nlm.nih.gov/pubmed/31525829.

7. Diego M, Field T. "Moderate pressure massage elicits a parasympathetic nervous system response." International Journal of Neuroscience. 2009. https://www.ncbi.nlm.nih.gov/pubmed/19283590.

8. Rapaport M, et al. "A preliminary study of the effects of repeated massage on hypothalamicpituitary-adrenal and immune function in healthy individuals: a study of mechanisms of action and dosage." Journal of Alternative and Complementary Medicine. 2012. https://www.ncbi.nlm.nih.gov/pubmed/22775448.

9. Moyer C. "Does massage therapy reduce cortisol? A comprehensive quantitative review." Journal of Bodywork and Movement Therapies. 2010. https://www.ncbi.nlm.nih.gov/pubmed/21147413.

10. Mense S. "Innervation of the thoracolumbar fascia." European Journal of Translational Myology. 2019. https://www.ncbi.nlm.nih.gov/pubmed/31579474.

11. Wilczynska D, et al. "Evaluation of the effectiveness of relaxation in lowering the level of anxiety in young adults—a pilot study." International Journal of Occupational Medicine and Environmental Health. 2019. https://www.ncbi.nlm.nih.gov/pubmed/31608900.

12. Reynolds S, et al. "Effects of deep pressure stimulation on physiological arousal." American Journal of Occupational Therapy. 2015. https://www.ncbi.nlm.nih.gov/pubmed/25871605.

13. Takamoto K, et al. "Compression on trigger points in the leg muscle increases parasympathetic nervous activity based on heart rate variability." Journal of Physiological Sciences. 2009. https://www.ncbi.nlm.nih.gov/pubmed/19340540.

14. Möller E, et al. "Infant crying and the calming response: parental versus mechanical soothing using swaddling, sound and movement." PLOS ONE. 2019. https://www.ncbi.nlm.nih.gov/pubmed/31017930.

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