Case Study: Getting the benefits of a massage treatment to “stick”
The following question was asked in AMT’s private Facebook group.
Massage Therapist, Toby Coy, took up the challenge to help.
I have been seeing a client weekly for 3 weeks.
She’s also seeing a chiropractor, who hasn’t diagnosed a specific problem but the client says she feels better after chiropractic adjustments.
The client loves cycling and swimming but feels restricted in her movement and has pain, which is all around her neck and anterior and posterior shoulder.
I’ve been needling, cupping, using a massage gun, and manual techniques.
It’s always slightly improved after treatment but that improvement isn’t maintained.
I want to know how to make the benefits of my treatments build and be retained.
The short answer is: look at the whole person, then figure out a way to build tolerance instead of simply relieving things.
First, I would discourage looking for specific dysfunctions related to twisting, anterior/posterior balance or posture because it is very easy to find something that is tight, weak or otherwise not perfect and assume that it is the problem. What about the staggering number of people we see with tight muscles, asymmetrical posture, some degree of muscle weakness and no symptoms at all? Top level athletes have tight muscles too.
Instead, I suggest zooming out a little to look at the context that this problem is occurring in. This is not a performance problem – the client isn’t coming in with a main goal of making her cycling or swimming more efficient. This is primarily a symptom-based problem. The aim is for them to feel better and for that to stick. There is overlap between the two but let’s give our attention to the primary issue.
Consider why things tend to get sore to begin with: in crude terms, we get uncomfortable when our stressors (physical/mental/emotional) exceed our tolerance. Begin by trying to get a sense of those factors:
1) When did the problem start? Did something change? Did the client start cycling more? Has the client started a new, demanding job?
2) What makes the client’s symptoms worse? Specific activities, fatigue, time of day, sleep quantity or quality, stress.
3) What makes the client feel better? Exercise, manual therapy, relaxation, lying down, a hot shower, weekend Vs weekday etc.
4) What is the client’s coping strategy for their pain? Sometimes their coping strategy is unhelpful. Canadian physiotherapist, chiropractor and strength and conditioning specialist, Greg Lehman, has a good approach, in which you can imagine the two unhelpful extremes as ends of a spectrum. On one end we have the “persisters”, who keep doing the aggravating activities and don’t let things settle down – their system is constantly being tested and aggravated. On the other end, we have the “avoiders”, who over time have been doing less and less due to fear of aggravating their symptoms, e.g. someone who has completely stopped using their right hand at work because it hurt.
Persisters need help settling things down, often by reducing their aggravators in the short term. Massage can be useful here. They can then gradually return to their normal loads.
Avoiders need to be encouraged to get back to the things they enjoy in a safe way. For avoiders, building their confidence to use the sore area and re-engage with life in the face of pain may be the primary therapeutic goal.
Both require a respectful conversation about the disconnect between what they are currently doing and the path to where they want to be.
Now we tie it all together.
In the short term, you can advise the client to change or eliminate their aggravating activities to allow things to settle down. OR you can significantly increase the density of relieving activities so that they stay below the threshold for aggravation.
In the long term, we need to look to the bigger picture. Massage is a reliever but it does nothing to build resilience to an activity. This is why massage therapists can easily get stuck in a loop, like that described in the question: the MT feels like they’re helping because the client feels better for a while, but it doesn’t ‘stick’.
How could anything we do ‘stick’ when the biggest contributing factors are not addressed?
Such as:(a) A client has started a new exercise and is overdoing it. The muscle overload is leading to calves that feel stiff. We massage them and they feel better for a few days but the tension keeps coming back. They haven’t stopped the exercise or changed the volume to make it more reasonable. We should not be surprised that our massage doesn’t stick. The thing that is making them feel tight is still happening.(b) A client has a stressful job. When they are stressed, their upper traps feel tight. We massage their traps and they feel better for a few days but they still have a stressful job and their traps keep feeling tight. Once again, we should absolutely expect that to happen. Massage is only temporarily changing how the neck feels, it is not resetting anything or fixing the underlying problem of unmanaged stress.
Our goal should be to make the client more resilient and able to self-manage. Client (a) may need a better training progression so that resilience can grow. Client (b) may need to implement better stress management tools into their week so that work doesn’t wear them down so much.
In both cases, the way forward emerges from the thorough history we took in the beginning.
In the case discussed in the question, a solid choice would be to get them in touch with a physiotherapist or exercise physiologist to discuss strengthening the areas that are sore. Stronger muscles can tolerate more activity, and the act of loading muscle is also an effective form of pain relief. Put another way, if your case history indicates that specific activities tend to be painful, it is reasonable to refer them to someone who specialises in the pacing, progression and facilitation of physical activity. Massage can’t address pacing or progression directly.
If your client has been cycling or swimming the same amount and in the same way for a long time and has only just started getting issues, it would be wise to see what else has changed to set this off. Perhaps their neck muscles are fine and things can return to normal if they go back to their prior sleeping habits, drinking less, or whatever it was they were doing before. Often it is enough to simply do more of the things that we love, which tends to reduce stress overall. Keep a broad perspective.
I highly recommend this article by Greg Lehman, in which he outlines the idea of building overall capacity rather than needing to specifically correct anything:
Toby Coy is a Remedial Massage Therapist based in Sydney. He enjoys tennis, reading, cooking and computer programming. His professional interests are in the implementation of biopsychosocial care and exploring what we are actually doing during manual and exercise therapy. He has dreams about developing software to make BPS care easier to implement.