Massage therapists, in my experience, often get asked questions during therapy sessions. Questions such as, “does that feel tight?” Or, “What is a muscle knot? It feels like I have a bunch!” Also in my experience, massage therapists have really bad answers for these questions. Throughout my career I’ve thought about these questions. I've learned and accumulated a lot of answers. The following is an amalgamation of what I think to be the most likely, evidence based answers to some of these common questions. These answers come from many experts. Most of whom have thought about this much longer than myself. Massage therapists, physical therapists, and PhDs. I’ll link their sources below. But the truth is we don’t fully know. More research needs to be done!
In 2002 a group of researchers out of Canada published a paper about the biomechanics of chiropractic adjustments (Bereznick, Ross & McGill, 2002). The paper demonstrated that the interface between the skin and underlying connective tissues is almost frictionless. This means it is extremely slippery, and that there is virtually no friction between the adjacent tissues. If you’ve paid attention so far, the realization might be hitting you. This has severe ramifications in the way we think about manual therapy! Could we be moving skin and barely affecting underlying tissue?
The popular notion among massage therapists is we’re “melting fascia,” and changing connective tissue with our hands. These narratives are pervasive, but not based on any evidence. There’s a reason for this. Much of massage therapy is rooted in tradition. To understand why, we need a brief history. After the introduction of the Food and Drug Act of 1906 (foundation of the FDA), interest in ‘alternative’ forms of healthcare waned. Pharmaceuticals, and other forms of therapy were the mainstream. Research into massage therapy all but stopped. That was an unfortunate turn of events for the massage industry. Luckily we’re back into researching massage therapy as of around 1980, but false ideas have had plenty of time to take hold. Oral traditions, and non-scientific teachings about massage therapy is still upheld in schools and CEU courses today. This needs to be addressed, and unfortunately there is often a ton of push back from other practitioners. I know because I was one of them.
I remember, not long ago, reading these ideas and thinking, “I need to unlearn everything I've learned thus far.” At the very least I needed to interpret what I knew through a different lens. It’s daunting. To think the knowledge I’ve accumulated over the years has misguided my practice.
The evidence suggests much of benefit we receive from massage, and manual therapy is neurophysiological in nature. We’ll unpack that more later. Basically, it’s based on the client’s brain and nervous system. When we touch someone, the frictionless, sliding skin organ feeds our nervous system tons of new (novel) sensory information. Most therapists look right past the skin organ, and all of the nerves embedded within, towards muscle and other tissues. Other tissues that we are likely affecting less than we think. Remember the sliding, frictionless interface.
“The human body has 45 miles of peripheral nerve. Moving nerves therapeutically and strategically helps to maintain their physiological and biological health. Healthy nerves that are well fed and drained through adequate and varied movement do not contribute to pain experiences. Sometimes however, because of many reasons which may involve pathological processes, or through injury long ago, too much of one kind of movement, or not enough variation of movement, nerves can develop tunnel syndromes (a cranky nerve whose tunnel has become a compressive or tensional threat to the neurons inside of it).”
-Diane Jacobs, Dermoneuromodulation
With this information in mind, we need to consider the highly innervated, mobile, and force dissipating skin organ, and the miles of nerve traveling towards it from deeper nerve trunks, into more superficial cutaneous nerves in the skin. When touching skin, we’re touching brains. Again, the ramifications this information has to our work are huge! It also implies it’s less about the skill of our hands changing the structure of tissue, and more about the skill of our hands providing therapeutic information, and movement of nerve. Learning this information must inform massage therapists in their practice. “No pain, no gain” forms of therapy make sense only if we think we’re changing the structure of fascia with our hands, elbows, and soft-tissue tools. Instead, if we realize every touch is a form of input for the nervous system, we should seek to comfort and relax. It should feel good, and non-threatening. It should also allow for healthy, and safe movement of nerve.
Even if we were able to get through the frictionless interface between skin and connective tissue, as mentioned earlier, the very act of changing/deforming fascia structure with our hands is impossible. To explain this we need to discuss the difference between elastic and plastic change. The tissues deform in one of two ways: elastic deformation or plastic. Elastic deformation occurs with smaller force loads. When this happens the tissue deforms slightly, and then immediately recoils to the original state when the force applied is removed. Plastic deformation occurs when the force load is more significant. Meaning, strong enough to deform the tissue well beyond normal. Once the force is removed the tissue does not recoil/return to the original state because the force was sufficient to change the shape and properties of the tissue. What is significant enough force? 1013 lbs of force (460KG) is required even for a 1% change in tissue structure (Chaudhry H, et al. Three-dimensional mathematical model for deformation of human fasciae in manual therapy. J Am Osteopath Assoc. 2008;108(8):379-90).
You might be thinking, “I’ve seen beneficial results from deep myofascial therapies that were extremely uncomfortable!” Post hoc ergo propter hoc (Latin: “after this, therefore because of this”) is a logical fallacy that stays: “Since event Y followed event X, Event Y must have been caused by event X.” Because beneficial results were obtained from deep, painful myofascial release does not mean the beneficial results were due to the fascia being released. Let me suggest an alternative hypothesis.
Descending Noxious Inhibitory Control
Descending Inhibitory Control (DNIC) is one of several ways the brain modulates nociception (danger signals in the body) by preventing them from moving up the spinal cord into the brain. Pain expert Lorimer Moseley views DNIC as a way for the brain to “second-guess” the periphery about the threat posed by a particular stimulus. DNIC is triggered by sustained nociceptive input, or a frequent danger signal. One example might be dipping your hand in ice cold water. This would help with pain in your hand due to the extreme temperature. But interestingly, dipping your hand in ice water would also help inhibit pain elsewhere, like that ache in the low back. It is known as “Counter-Irritation.”
It gets more complicated. There are factors that can change DNIC. Novelty, and expectation.
Novelty means something new. The brain craves new information. If you keep dipping your hand in cold water you won’t keep getting the same beneficial results. Unless you keep dropping the temperature, or increase your submersion time.
Expectation is also factor. What do you expect to happen when you dip your hand in the water? It plays a HUGE role in the outcome. In a study, researchers immersed the hands of participants in cold water, shocked them with an electric blast to the sural nerve, and then measured the level of nociceptive activity in the spine, as well as the self-reported pain level. Importantly, the participants were divided into two groups. The first group, called the “analgesia group”, was told that the cold water immersion would reduce the amount of pain they felt from the shock. The other group, called the “hyperalgesia group” was told the opposite - that cold water immersion would make the pain worse. The analgesia group experienced 77% less pain, and less spinal cord nociceptive activity than the hyperalgesia group, who experienced almost no reductions in pain or spinal cord nociceptive activity. In other words, expectation of relief was a huge factor in determining whether DNIC worked.
It could be that expectation of relief from myofascial therapy is the biggest determining factor for results in pain relief. The deep, sometimes painful pressure of myofascial therapy is our ice water. Counter-irritation is a fitting name.
This Shouldn't Get Under Your Skin
New information and research on massage therapy will continue in the near future. This is good news. We should be open to new information rather than threatened by it. Even if it's uncomfortable and we have to let go of some old ideas. We should always seek the truth.
Knowing that the brain and nervous system's role is important in massage therapy has some considerations. The brain takes into account biological, psychological, and social factors when producing pain and tension. Pain is a protective alarm. That is why comfort, and reassurance is important in massage therapy. Clients need to know their bodies are capable of adaptation, resilient, and do not require our hands to "fix" them. Do we really want to feed the brain false information about fascial adhesions, weakness, and reliance on our particular brand of massage therapy?
In my opinion there is much good that massage therapists can do for people. Armed with the right information, we can be potent facilitators of healing in our clients. Empowering people by giving them the tools they need to help themselves. If you're not a massage therapist, or another practitioner of some kind, I hope this information gives you some guidance on what to look for in your next massage appointment.
‘Dermoneuromodulation,’ by Diane Jacobs
“Why We Don’t Elongate Fascia,” Academy of Clinical Massage, Whitney Lowe
‘Massage Therapy: Integrating Research and Practice, Trish Dryden & Christopher A. Moyer
Massage, Sports Massage, Massage Therapy, Massage Therapist, San Luis Obispo, SLO, Empower SLO, Empower Movement + Massage, Clay Van Schoyck, Certified Massage Therapist, Certified Personal Trainer, Wellness, Health, Pain, Injury