If you don’t know how to do something, then don’t do it

“Do no harm” is written in stone for us, just as it is for all healthcare professionals, including—but not limited to—physical therapists, chiropractors, and physicians

From the author

There are many painful musculoskeletal conditions in which massage therapy can be helpful. There are also many stress-related illnesses where massage may provide significant benefit. Massage can be helpful in post-concussion rehabilitation and in many other conditions as well.

Yes, within an integrative medicine approach, massage therapy can contribute a great deal—but only if the therapist is properly trained to perform specific medical massage protocols.

Training must always be conducted by instructors who have acquired extensive clinical experience performing the specific protocols they teach. Proper training includes not only general fundamentals, but also the critical details required to achieve results—and, most importantly, how not to cause harm.

“Do no harm” is written in stone for us, just as it is for all healthcare professionals, including—but not limited to—physical therapists, chiropractors, and physicians.

Specialization Matters

I always teach my students by asking a simple question:

Would you allow your car brakes to be repaired by an auto mechanic who specializes in transmissions?
Both are licensed mechanics.

Then I ask another:

Would you receive a massage for a lower back disorder from a licensed massage therapist who has never been trained or specialized in that specific protocol?

As a well-known principle states:
Do not do to others what you would not want done to yourself.

A Real Clinical Case

Last week, I received a call from a lawyer who had previously been my patient. He was originally referred to me by a physical therapist for a very complex lower back disorder. The clinical picture was compromised, and MRI findings were severe. Two orthopedic surgeons had recommended surgery.

However, that physical therapist believed we could challenge the surgical recommendation. Using an integrative approach, we not only prevented surgery but restored full function. Nine years later, this patient remains fully functional—working out, hiking, and living an active life.

I mention this case to illustrate that he is a strong believer in alternatives to surgery.

The Request

He asked me to evaluate whether a massage therapist might have caused harm to his girlfriend. I agreed, because standard massage therapy does not cause conditions that require emergency spinal surgery. Only extremely vigorous, forceful pressure—something I do not consider massage therapy—could potentially cause trauma.

This is also why professional liability insurance for massage therapists is relatively low. Insurance companies assess risk carefully, and massage therapy is considered a low-risk practice when performed appropriately.

What I discovered in this case was surprising—and important for all of us to learn from.

Case Presentation

• Patient: 45-year-old female
• Occupation: Executive Assistant

Four months earlier, she received a massage at a local spa. After the session, while walking down the stairs to the parking lot, she realized she had left her cell phone upstairs and returned to retrieve it.

As she was walking back down to the parking lot, she suddenly felt—as she described—“like a train hit my lower back.” Her right leg became weak and gave out. She managed to avoid a major fall but ended up on the floor, screaming and begging for help.

Most frightening to her was the sudden loss of bladder control.

She was transported by ambulance to the emergency room, where a CT scan revealed an annulus fibrosus tear with nucleus pulposus protrusion into the spinal canal. Several hours later, she underwent emergency spinal surgery.

Clinical Interview

My first question was:

“Did you have right-sided low back pain radiating into your leg before the massage?”

Her answer was yes—she had experienced low back pain for several months.

I replied that she had likely already undergone imaging, which showed 4 mm bulging discs at L4–L5.

My second question:

“Did you come to the spa specifically for a lower back massage?”

She said yes and added that her pain level was less than 5 out of 10 at the time.

I asked whether she booked a one-hour or two-hour session.

She booked one hour.

I then asked whether the therapist spent the entire hour working on her lower back.

She answered yes.

I asked whether the therapist applied vigorous pressure that caused pain.

She said no—if it had been painful, she would not have allowed the session to continue.

I asked how she felt when she stood up from the table.

She said she felt slightly dizzy.

When asked about her pain level at that time, she reported it was the same or perhaps slightly worse.

Conclusion and Advice

The emergency room report clearly stated no evidence of trauma. She did not report increased pain during the massage itself. Therefore, the disc protrusion was most likely coincidental.

I advised her to focus on continued recovery after surgery and not to pursue legal action against the massage therapist.

My Professional Opinion (Not Expressed to the Patient)

I did not express my full opinion to her.

Professionally, I believe the massage therapist did contribute indirectly to this chain of events by overstimulating the tissues and increasing paravertebral muscle tension. This may have reduced the muscles’ ability to support weight-bearing. When load was transferred to an already compromised disc, it could no longer withstand the pressure and herniated.

Some may say this was not honest.

This was not about honesty—it was about responsibility. Overstimulation is not objectively provable. Sharing this opinion could have confused the patient, encouraged a lawsuit that would not succeed, added unnecessary stress, and distracted her from recovery.

Final Thoughts

I am 100% convinced that this therapist was not trained to treat lower back conditions involving radiculopathy. She had no ethical right to perform work she was not trained to do.

I hope she reads this piece.

For those who have not read my article “The Dangers of Overstimulation,” I strongly encourage you to do so (link below).

Even now, as I write this, I remain convinced that the massage therapist contributed to this tragic outcome. Perhaps the disc could have herniated eventually—but possibly not in this way, and not at this time.

Had this patient been treated by someone properly trained to handle such a case and capable of safely decompressing the spine, she might have continued living a full life without ever facing surgery.

As always, you are welcome to post questions, comments, or disagreements.
Please let me know your thoughts.

https://www.medicalmassage-edu.com/blog/danger-of-overstimulation.htm

From the article

Understanding Overstimulation

Normal resting muscle tone is about 50% muscles constrictions. Under general anesthesia, muscle length doubles, but when the patient awakens, muscles shorten back by 50%.

Overstimulation occurs when a therapist eliminates pathological tension but continues working, challenging the body’s normal 50% muscle tone. The result is unpredictable: in this case, painful spasms.

Best wishes,
Boris Prilutsky