Beneath the surface: recognising complex health patterns in massage therapy

by Nicola Hogan

Did you know that May is Ehlers-Danlos Syndrome (EDS) awareness month? It’s a timely reminder for us to stay curious and informed about connective tissue disorders and the often complex, whole-body presentations that may sit beneath the surface, especially in clients who are undiagnosed.

Broadly speaking, EDS is characterised by joint hypermobility but this is only one piece of a much bigger picture. It’s a connective tissue condition that can show up across multiple systems in the body, not just the joints. In practise, this means symptoms can be wide-ranging and often seemingly unrelated at first glance.

Common presentations may include:

• Joint hypermobility
• Joint subluxations and dislocations•
• Ongoing joint and muscle pain
• Fatigue that feels disproportionate to activity
• Easy bruising
• Digestive issues
• Postural Orthostatic Tachycardia Syndrome (POTS: dizziness, or light headedness on standing)
• Headaches and migraines
• Cranio-Cervical Instability (CCI)
• TMJ dysfunction and jaw tension
• Pelvic and urogenital symptoms.

There is also increasing recognition that conditions such as POTS and Mast Cell Activation Syndrome (MCAS) may co-occur with EDS, adding further complexity to the clinical picture.

Patterns I’ve noticed in my clinic

In recent years, I’ve been seeing a recurring picture: women aged 38–54 presenting with layered, whole-body symptoms that rarely fit a single diagnosis and are frequently put down “stress”. Clients are often juggling full, demanding lives with work, family, and relationship commitments so they arrive feeling simultaneously exhausted and wired. Rest doesn’t always come easily to these clients, even when the opportunity is there. From a musculoskeletal perspective, there are some familiar themes: persistent neck and shoulder tension, jaw pain, clenching or grinding, and a general sense of muscular guarding. Along with this, there are often broader systemic concerns: gut issues, fatigue, heightened sensitivity to pain or stressors, and autoimmune presentations.

I have also recently seen a number of clients exploring or receiving late diagnoses of ADHD, which adds another layer to how they experience regulation, focus, fatigue, and overwhelm. Rather than seeing these as separate issues, what stands out is how interconnected everything feels in the body.

Hormonal transition

Many of these clients are also moving through perimenopause or menopause, which can significantly influence how all of the above presents. Fluctuations in oestrogen and progesterone can affect sleep, mood, pain perception, temperature regulation, and overall resilience. Clinically, this often shows up as increased fatigue, disrupted sleep, anxiety, and a reduced capacity to recover from stress.

For some clients, this transition seems to amplify pre-existing patterns, whether that’s joint instability, chronic muscular tension, or difficulty down-regulating the nervous system

An interesting clinical question is how hormonal shifts may interact with autonomic regulation, connective tissue integrity, and musculoskeletal load.

A more complex clinical picture

Many of the clients I have described here are already receiving “multidisciplinary care” but, in real terms, the approach is not always genuinely collaborative or integrative. Rather, clients are seeking care individually from their GP, physiotherapist, naturopath, pilates or personal trainer and receiving massage therapy as part of their broader support system.

One of my clients who recently turned 50 decided to undergo further investigation of her symptoms, based on her own ADHD diagnosis, having a son with autism, and an extended family history of neurodivergent and autoimmune conditions. Her search for answers led her to an integrative medical service that explores complex, multi-system presentations across connective tissue, autonomic nervous system, immune, neurological, and hormonal pathways. Her assessment and treatment are ongoing but massage therapy remains included in her current care plan. For this client, an initial diagnosis of Connective Tissue Disorder and Cranio-Cervical Instability have provided much relief, like the missing piece of the puzzle has finally fallen into place. She now feels more empowered, with a team of practitioners working collaboratively to support her health.

What the emerging research Is telling us

ADHD in women is often under-recognised and can be diagnosed later in life, partly due to historically narrow diagnostic frameworks. There is also a growing body of evidence around the relationship between joint hypermobility and neurodevelopmental conditions, including ADHD and autism traits. Hypermobility may contribute to differences in proprioception, pain processing, and muscular compensation patterns.

Autonomic dysfunction, including POTS, is associated with symptoms such as fatigue, dizziness, palpitations, and characteristic neck and shoulder pain presentations. Hormonal transitions may further influence autonomic stability, although this is still being researched.

When you bring these threads together, a more interconnected picture of the body starts to emerge: one where neurological, hormonal, immune, and musculoskeletal systems are constantly interacting.

A recurring question

Could it be that some of the clients we’re seeing now – those receiving more detailed investigation and layered diagnoses – are the same people who might previously have been grouped under broader labels such as fibromyalgia or chronic fatigue syndrome? These diagnoses remain valid and important. But as research evolves, there’s a shift towards a more nuanced understanding of complex, multi-system presentations that were once considered “medically unexplained”.

For us as massage therapists, this is less about finding answers and more about staying open to changing perspectives.

Where massage therapy fits

Massage therapy still has a very clear and valuable role, even with the complexity and ambiguity of clients presenting with multi-system conditions.

Clients often report that massage therapy brings both muscular relief and a sense of nervous system settling. For clients with more complex presentations, flexibility in approach is more important than following a fixed routine. This might include:

• working within safe, comfortable ranges for hypermobility
• adjusting pressure and pace based on fatigue and sensitivity
• supporting nervous system down-regulation
• creating space where rest feels accessible.

Where appropriate, additional techniques can be used within scope. Lymphatic drainage techniques may offer gentle support for clients experiencing systemic sensitivity or fatigue. Thermotherapy, can also be helpful. Heat (such as hot stones or warm compresses) may support relaxation and ease muscular tension, while cold can sometimes be useful for calming more reactive or inflamed areas, depending on the individual presentation.

As always, it’s about responding to the person in front of you, not just the condition.

Collaboration matters

Communication between practitioners is even more crucial when working with clients who present with complex health conditions. This may involve working alongside and, with client consent, sharing case information with GPs, psychologists, or other allied health professionals. It can also include sharing relevant observations within scope or aligning treatment goals to support a more integrated care plan.

This kind of collaboration strengthens continuity of care and reinforces massage therapy as a vital part of the broader healthcare ecosystem.

Some final thoughts

As massage therapists, we are not diagnosing, and we’re not even trying to! But we are in a position where we see patterns over time that other health practitioners may not always observe. That brings both responsibility and opportunity: to stay curious, to keep learning and to adapt how we work as new information and research emerges.

Sometimes, the most valuable thing we can offer our clients isn’t actually a technique or a modality but rather the experience of being met with attention, consistency and skilled, responsive touch amidst complexity.

About the author

With 25 years of clinical experience, Nicola is known for her thoughtful, client-centred approach and deep interest in the human dynamics beneath touch. Her work is grounded in “tales from the table” – the patterns, conversations, and insights gained through hands-on practice. She has also supported therapists as a mentor in the AMT pilot mentoring program, trained and mentored staff in her clinical business Stress Less Bodyworks, and worked as an advisor through the government funded ASBAS program, helping practitioners with their digital marketing capability to communicate with clarity.