Take the pressure down
by Aran Bright
If you were around in the 80s, there is a very good chance you now have a Johnny Farnham inspired ear worm to deal with. As it turns out, John also had very good advice for massage therapists and their clients, even though he was probably singing about the impacts of stress and loneliness on society, and a desire to sail away to a desert island. He was way ahead of the curve on the evidence for application of pressure in massage therapy.
So this is a blog about three main things:
- why you should be carefully considering (or reconsidering) the use of heavy manual pressure during treatment
- why you should be an advocate for moderate pressure interoceptive experience and
- why you should be educating your clients with a neurological explanation for the effects of massage.
In other words, we will be dismantling the common belief that massage therapy needs to involve painful pressure to “fix” or “correct” something in the body. I hope that by the end of this read, you will not only be convinced that “no pain, no gain” is completely wrong, but also feel motivated to advocate for and educate others on the truth that massage doesn’t need to be painful, and tissues don’t need to be broken up under pressure.
This belief that deep, painful manual work is necessary for healing seems to be very heavily ingrained in society. There are many reasons for this, including the need to “get knots out of the muscle”; that something needs to be “put back into place”; and the old chestnut that heavy pressure is required to “break up” tissues.
If the issue is with the tissue, then I guess it’s logical that the more pressure you use, the better. I mean, if something needs to be stretched or tenderised, moved or compressed, then a bigger hammer is always better, right?
So let’s look at the concept that you need heavy pressure to relax a muscle or “break it up” in some depth (‘scuse the pun).
I am going to assume that you, honourable reader, have already dispelled the myths that there are knots that form in muscles and joints that go “out of place”. Sam MacCracken wrote an excellent blog post on perceptions of muscle tightness on this very blog back in 2018 which addresses these perceptions.
Hopefully, you are also already aware that we cannot remodel or stretch fascia, myofascia or any other soft tissue to the point of making it longer (with some very minor exceptions that will be of no use to a massage therapist). Source
In fact, the idea that massage “breaks up” tissue has been a dead duck since at least 2003. It is worth quoting Robert Schleip (generally accepted as one of the world’s leading researchers on myofascia) directly on this topic:
…studies have shown that either much stronger forces or longer durations would be required for a permanent viscoelastic deformation of fascia … A change in attitude in myofascial practitioners from a mechanical perspective toward an inclusion of the self-regulatory dynamics of the nervous system is suggested…
Robert Schleip, 2003
What is going in with massage, pressure and touch?
When a therapist applies pressure to the skin, there are biological mechanisms that are triggered. The pain gate model is one example of a neurological response to pressure. Source The TL;DR version of gate control theory is that, when the receptors of the skin are stimulated sufficiently (think, good moderate massage pressure), nociceptive signalling is reduced, triggering a decrease in pain experience. This is the most common explanation for why pleasant stimuli like massage have an effect on pain.
Another biological mechanism that has been posited is descending inhibition. Source This is the mechanism by which the brain can self-regulate and reduce the experience of pain. Key concepts include endogenous opioid secretion (your brain’s very own internal drug cabinet) and temporal summation … which we can file under “your brain does some cool stuff to reduce pain”. Descending inhibition can be triggered by trauma but, in a clinical context, it is normally triggered by the therapeutic environment (safe space), the therapist-person interaction, and the client’s beliefs around capacity for healing (think placebo or non-specific effects). This is an overall effect of any therapeutic experience.
Another on-trend explanation is that moderate pressure massage triggers a gentle vagal response (not a vasovagal response, that’s completely different) Source In other words, the pressure of massage triggers the response that is associated with vagal nerve stimulation, which in turn stimulates the parasympathetic nervous system. Parasympathetic nervous response leads to a relaxation of skeletal muscle tissue, a decrease in breathing and heart rate (and therefore the symptoms of anxiety), stimulation of digestion, and overall makes you feel relaxed. Theoretically then, it could be argued that painful massage works against the goal of reducing muscle tone.
So how the hell do muscles “soften” then?
You may be surprised to discover that there is not a lot of research on what the softening that occurs in the body during a massage is. In fact, we know more about what it isn’t than what it is.
When it comes to muscle relaxation, the most accepted mechanism is that the body’s nervous system will reduce the resting tone of muscle. In short, the body can adjust the amount of contraction that a muscle holds at rest. This is the best current explanation for the muscle softening you feel with massage. Source
When it comes to targeted muscle relaxation, one great study demonstrated that direct massage, indirect myofascial techniques and muscle energy techniques all reduce resting muscle tone with no real difference between the three methods. Source For those of you not aware, indirect myofascial technique does involve some pressure, but it is about placing the tissues in a position of ease to allow a decrease in resting muscle tone. Muscle energy technique, particularly when performed with osteopathic protocols, does not involve stretching or any manual compression of the target muscle, instead it is a gradual lengthening combined with muscle contraction. In other words, you can reduce local muscle tone with direct pressure, indirect pressure (or positioning) or via positioning and muscle activation with no touch.
In summary, you can indeed reduce muscle tone with no touch at all. Nothing needs to be “broken up” and direct pressure can help but is not necessary.
It is also worth noting that focused relaxation methods, such as meditation, progressive muscle relaxation and gentle movement can also relax muscle tone, with no touch or practitioner intervention required.
The interoceptive model of massage
Interoception is the word to describe someone’s internal bodily sensations, such as feelings of tension, anxiety, digestion or any other internal body sensation, separate to the 5 external senses, proprioception and vestibular (balance) senses. The key interoceptive sensation for massage therapists is the feeling of muscle tension and sensitivity.
Which gets me to the nub of this post, which is to posit the following explanation for why massage therapy can be so effective at reducing pain and sensations of muscle tension.
Massage therapy creates an interoceptive experience, where sensations of muscle tension and sensitivity can be brought to the level of conscious awareness. In the right setting, this can lead to a client-led relaxation of skeletal muscle tone, and activation of pain modulation processes such as pain gating, descending inhibition and vagal responses.
So rather than massage being a process where the body’s tissues need to be mechanically stretched, massage therapy is a process of assisted self-exploration of body tissues, where it is possible for self-regulation and relaxation to occur, including a relaxation of muscle “tension”.
Summary
Hopefully, you are convinced that heavy pressure is not required to achieve a decrease in resting muscle tone. Comfortable, moderate massage pressure provides a facilitated experience of the body’s tissues where a client can focus on targeted tension or sensitive areas, and hopefully achieve whole-person relaxation, targeted muscle relaxation, and pain modulation.
As a corollary, I invite you to consider how you use your own body when performing massage and how you communicate with your clients. Are you trying to achieve maximum pressure or maximum awareness for your client? Are you perpetuating the myth that massage has to be painful to be effective? Are you making your clients aware of their own inherent pain-modulating capabilities?
And finally, are you ready to take the pressure down?
About the author
Aran is a massage therapist, myotherapist and educator. He lives on the Sunshine Coast in Queensland on traditional Jinibara country, where he runs a massage clinic with his wife Sheree. He also works for Q Academy, an RTO, teaching remedial massage and myotherapy. His interests include doing massage, researching massage and talking about massage.
He also plays tennis.
\
