Massage therapists use heat—a lot. From hot packs to heated stones and poultices, practitioners apply heat in many forms. Even in summer, our clients seem to love a hot towel or warmed table. So, why are we so fond of heat?

Massage therapists use heat—a lot. From hot packs to heated stones and poultices, practitioners apply heat in many forms. Even in summer, our clients seem to love a hot towel or warmed table. So, why are we so fond of heat?

Heated thermotherapies increase blood flow and cellular metabolism, which can help reduce muscle spasms, increase tissue elasticity and decrease pain. So, the real question may become, what’s not to love about heat when manipulating soft tissue?

How Thermotherapy Affects the Body

Heat induces viscoelastic property changes in collagenous tissues. A large systematic review found that heat increases range of motion (ROM) with these collagenous tissue changes.1 Additionally, the study concluded that a combination of heat and stretching is more effective than stretching alone.

Increased healing potential: In one study, a heating pad increased blood flow to the trapezius muscle up to 144% in healthy individuals.2 Increased blood flow applied to an injury site is thought to increase the supply of nutrients and oxygen to the injury, thus a promotion or potential acceleration of healing processes.

The Psychological Effects of Heat

Some thermotherapy benefits may be directly due to effects in the brain. Heat receptors in the body that detect non-noxious (non-painful) levels of heat may play a role in why heat decreases pain. Studies using brain imaging found that thermotherapies increased activation of the thalamus and posterior insula, two areas of the brain involved in pain processing.2

Pain relief from heat has been demonstrated to outlast medication too. Effects from continuous heat therapy were greater than effects of NSAIDs up to several days after treatment when compared to medication.3 Additionally, in several studies of the wrist and hand, those who received pain-relieving thermotherapies had reduced pain and increased muscle function when compared to the placebo group.2

Add Heated Thermotherapy to Your Practice

Massage therapy itself can increase the heat of tissue through the manual application of pressure and friction, but most heated thermotherapies work through conduction from an object or substance to the body. This includes anything from heated packs to tables to the materials or supplies added to massage. Here are some heated thermotherapy examples commonly used by massage therapists:

Table Warmers

Heated fleeces, biomats and electric blankets are all commonly used on massage therapy tables.

Hot Towels

Hot towels can be used to cleanse the skin prior to bodywork and can be applied pre-massage, to warm up soft tissue. Hot towels can be continually used during or after massage to abed soft tissue compliance and remove massage medium residue, such as massage oil or cream. In fact, it is good practice to remove all massage mediums applied to the feet after a massage session to prevent a client from slipping on the floor or in their shoes after their treatment.

Hydrocollator Packs also known as Moist Heat Packs

Water tanks with canvas packs are heated to up to 160 degrees Fahrenheit. The packs are usually filled with materials such as bentonite, which is an absorbent clay-like substance. These reusable packs are wrapped in sanitary barriers such as terry wrap or towel and then placed stationary on a client from 5 to 20-plus minutes.

Aromatherapy Bath or Shower

Adding thermal hydrotherapy to a massage session is a wonderful way to attempt to increase soft tissue compliance prior to hands-on bodywork. Adding essential oils to the thermal hydrotherapies may enhance the therapeutic effects. Steam rooms and saunas may also similarly initiate soft tissue compliancy.

Heated Poultice & Herbal Bolus Bag Treatment

Spices, herbs, plant materials and more can be specially encased in muslin and twine which create a ball on one end and a handle on the other. They can be handmade or store-bought, then heated and manually manipulated over the soft tissue of the body. Poultice and herbal bolus bag treatments can create a three-way therapeutic application via the soft tissue manual manipulation with the ball, the therapeutic effects of the efficacious material within the bag, and the thermal therapeutic effects.

Hot Stone Massage

Smooth black basalt lava stone is typically heated up to 130-plus degrees Fahrenheit. A trained practitioner can massage the client with heated working stones plus arrange placement stones over the client’s body on top of physical barriers such as sheets and towels. One study showed that simple placement stones on the abdomen increased distal skin temperature on the lower extremities. Heated basalt lava stones are thought to have energetical properties and benefits in addition to the thermotherapy application.

Heated Body Wraps

Body wraps are heated through two primary methods. First, a client can be wrapped in an element such as a heated blanket placed over the body wrap material. Second, some body wrap product manufacturers may include ingredients that will heat the body wrap mixture with adding moisture prior to dermal application and wrapping. It is thought that heat will provide a better absorption of the body wrap’s efficacious ingredients, thus an enhanced therapeutic application through thermotherapy.

Paraffin Treatments

Paraffin bath therapy has been deemed effective in reducing pain and maintaining muscle strength in hand osteoarthritis, along with many other therapeutic benefits. This thermotherapy is applied by melting paraffin wax in a small tank; or single-use heated bags of wax.

The heated paraffin can be painted with an esthetics brush onto a client’s back or other surface area (a practitioner may wish to avoid hair). The hands, elbows or feet can also be dunked into a tank or single-use bags.

And don’t forget to heat your massage oil, lotion or cream for clients who love thermotherapy. Heating your massage mediums may provide a client a whole new sensation of relief.

There are many more thermotherapies available in the marketplace today, including ultrasound machines and lasers, which may or may not be within a massage therapist’s scope of practice. Practitioners should seek specialized training prior to practicing new thermotherapy applications and follow equipment or supply manufacturer instructions when applicable.

Heated Thermotherapy Contraindications

Conditions where heat application should not be used include existing edema, diabetes mellitus, hematoma, multiple sclerosis, peripheral vascular disease, spinal cord injuries, menopausal women and rheumatoid disease.

Heat should not be applied to an acute injury, as it can increase swelling. In most cases, thermotherapy should not be applied to a skin rash, broken or recently incised skin.

A total exhaustive list of thermotherapy contraindications is not possible, as each medical scenario requires individual evaluation for potential contraindications and treatment options. Some clients could be contraindicated with a particular disease, such as arthritis, while other clients with the same disease are not, hence the need for continual professional assessment.

Hot Thermotherapy vs. Cold Cryotherapy Mechanisms

Nader, et al., states: “Although cold and hot treatment modalities both decrease pain and muscle spasm, they have opposite effects on tissue metabolism, blood flow, inflammation, edema, and connective tissue extensibility. Cryotherapy decreases these effects while thermotherapy increases them.”

Incredibly, while the physiological effect of hot and cold on the body are opposite, both can relieve pain. As such, it is ultimately the practitioner’s choice to select which modality will best serve their client’s individual needs with thermotherapy or cryotherapy application. Some practitioners will contrast hot and cold modalities, which is another acceptable practice in many cases.

PainDecreaseFootnotes 2, 3
Blood FlowIncreaseFootnote 3
Tissue Elasticity and Range of MotionIncreaseFootnote 1

The Ultimate Use of Thermotherapy

Heated thermotherapy applications used to enhance bodywork and massage treatments are typically inexpensive when compared to return on investment (ROI). In fact, thermotherapy application may make a physical modality such as deep tissue massage a little easier for the practitioner with increased tissue compliance and range of motion.

Adding thermotherapy could cost as little as $25 for some extra hand towels or poultices to a couple hundred dollars for a hydrocollator, hot stone or paraffin kit. When comparing this to the value of what could be charged for add-on or enhanced services, we feel it is worth the investment. Thermotherapy equipment may pay for itself with happy clients who can provide referrals and repeat appointments when they receive the best possible results and care for their soft tissue ailments.

Jacqueline Tibbett, PhD
Jacqueline Tibbett, PhD

About the Authors

Jacqueline Tibbett, PhD, and Selena Belisle are Approved Continuing Education Providers with the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). They teach soft tissue bodywork and rehabilitation in modalities such as myofascial release and share a combined 40-plus years of massage therapy industry experience.

Selina Belisle


1. Bleakley CM, Costello JT. Do thermal agents affect range of movement and mechanical properties in soft tissues? A systematic review. Arch Phys Med Rehabil. 2013;94(1):149-163. doi:10.1016/j.apmr.2012.07.023

2. Nadler SF, Weingand K, Kruse RJ. The physiologic basis and clinical applications of cryotherapy and thermotherapy for the pain practitioner. Pain Physician. 2004;7(3):395-399. doi:10.36076/ppj.2004/7/395

3. Nadler SF, Steiner DJ, Erasala GN, Hengehold DA, Abeln SB, Weingand KW. Continuous low-level heatwrap therapy for treating acute nonspecific low back pain. Arch Phys Med Rehabil. 2003;84(3 SUPPL. 1):329-334. doi:10.1053/apmr.2003.50102