Linda Derick responds
This is an exciting time of connection between the science of touch, manual therapy and pain research. We have evolved our profession dramatically over the past three decades. There have been more research studies and papers about the science of touch published in the last decade than in the century that came before it.
We have looked at the efficacy of massage therapy and its effects and benefits for a wide variety of special populations, with a primary focus on pain management.
The growing discussion, and the evidence, indicates that one of the most profound physiological mechanisms contributing to the efficacy of massage therapy is the clinical potency of relaxation.
In a 2016 study published in Journal of Pain Medicine, “The impact of massage therapy on function in pain populations—a systematic review and meta-analysis of randomized controlled trials: Part I, patients experiencing pain in the general population,” the authors concluded in their findings that, “although a growing body of evidence based research emphasizes the importance of human touch in facilitating healing and recovery from pain, the underlying mechanisms by which massage affects the body are still being investigated.”
Since 2015, the annual San Diego Pain Summit has provided an opportunity for pain research and manual therapy to come together, exposing some of the leading edges of our thinking about the mechanisms through which touch therapy can be effective in addressing pain.
“Started and run by a massage therapist [Rajam Roose], the San Diego Pain Summit brings together scientists, teachers and manual [and] movement therapists from many professions and countries to learn from one another and develop professional respect,” said Jason Erickson, who emceed the 2017 summit. “It is one of the greatest events any massage therapist can attend and feel at home.”
Two of the pain research presentations at the 2015 summit offered theoretical discussion and insight into the relationship between relaxation massage and pain relief. Barrett Dorko, P.T., discussed how mechanical deformation of the nervous system can generate pain. Diane Jacobs, P.T., explained that if nerves can’t get enough oxygen or glucose or are so compressed they can’t drain themselves sufficiently, the homeostatic imbalance that is created sends a signal to the brain about the problem, and this registers as pain.
Both Dorko and Jacobs suggest that in order to effectively work with the neurology of pain, touch therapy must not create pain or discomfort. Instead, sometimes touch needs to guide the client out of the flight-fight-freeze cycle into one of increasing relaxation, pain reduction and healing.
What the Research Says
Current touch research is yielding a fascinating basis for just how massage communicates to the receiver and stimulates far-reaching effects and benefits.
For example, in The Handbook of Touch (Springer Publishing Company, 2011), an article titled “The Molecular and Genetic Basis of Touch,” states, “Touch perception is a multistep process that begins at the peripheral nerve terminals of sensory neurons, where indentation of the skin activates mechanically gated ion channels that convert mechanical forces into receptor potentials. The next step is action potential initiation and propagation to the spinal core … [t]he final step is the central processing in sensory cortices and higher brain regions.”
Dorko cited the work of Paul Bach-y-Rita, M.D., (1934–2006), a neuroscientist who wrote about synesthesia, a neurological phenomenon where senses are melded. While the sensory pathway of touch follows a linear structural process, Dorko noted, the actual experience of touch can be more instantaneous and intuitive.
“The therapist adapts sensor data passing through their hands; it should be possible for them to experience the data stream by direct experience of perception,” wrote Dorko. “What the mind abstracts from the hand is the meaning of the data stream rather than the data points themselves.
“The hands would be used as a primary sensory organ, now known to be fully capable of sensing the patient’s movement and leading the therapist’s brain to a new sense of the activity before them,” Dorko continued. “This sense of the patient’s internal activity, in my opinion, will not mature when the therapist’s hands are too busy [or doing anything that arouses pain or discomfort].”
The Relaxation Response
With all that we have learned via pain research studies, it seems likely that the relaxation aspect of massage therapy could underpin many theories about how massage mediates pain, and perhaps even stands out as the primary mechanism.
The relaxation response, originally formalized by Herbert Benson, M.D., in the late 1960s, is the physiological response, generated through relaxation, that counteracts negative effects of chronic stress, helping the body and mind resolve stress and return to a state of calm homeostasis and well-being.
Long before the therapist arrives at the bottom of a trigger point, or before the fascia begins to unwind and melt, there is a cascade of neurophysiological activity initiating the potential for pain reduction for the client. In fact, it is also possible that in some cases, the busy-ness of the therapist or the arousal, by massage, of a pain reflex, could reduce or negate the ability of the massage to benefit the client, in terms of pain management.
Another article in The Handbook of Touch is authored by Tiffany Field, Ph.D. In “Massage Therapy: A Review of Recent Research,” she wrote, “Research is presented on moderate pressure as the critical massage therapy variable as well as potential underlying mechanism for the massage therapy effects.”
Too little pressure, and touch can be perceived as ticklish and agitating; too much pressure, and the pain threshold can be triggered, contributing to the client’s already aroused flight-fight-freeze cycle associated with chronic pain.
In a third article from The Handbook of Touch, titled “The Communicative Functions of Touch in Adulthood,” author Matthew J. Hertenstein concludes that the authors’ review of multiple studies “demonstrate that touch is capable of communicating distinct emotions from one person to another.”
As the therapist delivers massage via the communication of his own well-developed state of relaxed, calm attention—through the quality of his touch and the use of moderate pressure—massage initiates a flooding of the neuropsychological and biological systems with an invitation to relax.
The client’s response creates an environment that can support healing and pain relief at all levels.
Parallel to studies of touch therapies and pain science, medical science has been struggling with the problematic side effects of pharmacological pain options and seeking alternative methodologies to treat chronic pain—one of the most prevalent medical conditions in the U.S. today.
In the 2010 article, “The Effects of Massage Therapy on Pain Management in the Acute Care Setting,” published in International Journal of Therapeutic Massage & Bodywork, the authors wrote, “Pain management within the acute care setting is a concern that is being carefully examined not only by individual hospitals, but also by accreditation organizations across the U.S. … [r]esearch has documented the use of massage therapy as an effective tool for pain management with the added benefit of producing few adverse reactions.
“By accessing a patient’s ability to relax, massage therapy addresses a variety of needs,” the authors continued. “Indeed, the [relaxation response] may be the most profound mechanism through which massage therapy helps the hospitalized patient.”
Also in the 2010, the Pain Management Task Force Final Report, Providing a Standardized DoD and VHA Vision and Approach to Pain Management to Optimize the Care for Warriors and their Families, from the Office of The Army Surgeon General, proposed that “Stress is a significant contributor to pain conditions. In fact, by definition, pain has an emotional component. Further, chronic pain leads to increased stress, which leads to a vicious cycle.
“Therefore,” the report continued, “pain cannot be managed without addressing its relationship to stress. Research is showing that our thoughts and perceptions influence our ability to heal. Mindfulness focuses the mind’s ability to heal the body. This interaction is often missed in the disease based treatment model.”
Massage Therapy’s Role
The report lists massage therapy as a tier-one modality, based on research suggesting its safety and efficacy within a holistic, biopsychosocial model.
Effective in 2015, the Joint Commission, which focuses on accreditation of health care organizations, revised its standard regarding pain management in order to increase emphasis on the integration of nonpharmacological methodology for pain management.
“Both pharmacologic and nonpharmacological strategies have a role in the management of pain,” the revised standard states. “The following examples are not exhaustive, but [nonpharmacological] strategies may include the following: physical modalities (for example, acupuncture therapy, chiropractic therapy, osteopathic manipulative treatment, massage therapy, and physical therapy), relaxation therapy, and cognitive behavioral therapy.”
While we engage in finding—and funding—high-quality pain research studies to determine whether the mechanisms that we anecdotally think are responsible for the benefits of massage, let’s not lose focus on the role of the relaxation aspect of what we do in every session, regardless of technique or depth of pressure, as a basis for how massage therapy can be so very effective for pain reduction and management.
Take a deep breath, engage your own relaxation response, keep calm and continue to practice effleurage, convey kindness and listen carefully to your clients’ tissues.
Your clients will take it from there, as their own relaxation begins to flow through their body and mind, and they are more able to access the healing that they need.
About the Author
Linda Derick has been a massage therapist and educator for 30-plus years. She is director of the Connecticut Center for Massage Therapy. Her leadership weaves together academic studies in movement from Wesleyan University, contemplative education from Naropa University, and her evolving avocation as a certified yoga instructor, specializing in stand-up paddleboard yoga. Her articles for MASSAGE Magazine include “Compassion for Self, Compassion for Others: The Interplay of Ethics & Self-Care” and “Meditation Improves Quality of Touch.”