An illustration of a transparent human body, nerves illuminated with different colors, is used to illustrate the concept of acute and chronic pain.

Massage therapists work with clients’ pain every day—and while some clients present with acute pain, others present with chronic pain. With a solid understanding of acute vs. chronic pain, massage therapists are better equipped to address a pain patient’s complex needs.

Acute vs. Chronic Pain

Acute pain results from injury, surgery or illness and generally resolves when the cause is addressed. Chronic pain is more long-lasting and affects a large number of people in the U.S.

More than 20% of the U.S. population lives with chronic pain, or pain lasting three-plus months, according to the U.S. Centers for Disease Control & Prevention.1 About one-quarter of massage clients (24%) choose massage to relieve or manage pain1, 94% of massage consumers consider massage effective in reducing pain2, and receiving massage for chronic pain was more common (16%) than for acute pain (9%)2.

Chronic pain is different from acute pain and presents unique challenges for both client and massage therapist. Pain has been defined asan unpleasant sensory and emotional experience associated with actual or potential tissue damage”3,4; however, acute pain has an obvious cause that heals and the pain goes away, whereas the onset of chronic pain usually cannot be traced to a single origin and the pain is not going away.

Because chronic pain has no well-defined cause, there is no single protocol to follow for massage treatment. Persistent pain may shift locations and vary in duration, intensity and onset. Developing a basic understanding of pain can help massage therapists create realistic plans to address problematic conditions and improve quality of life.

With chronic pain, the nervous system sensitizes to unrelenting pain signals5. An ongoing sense of danger can trigger anxiety, depression, difficulty sleeping, and a sense of alienation in your client.

People living with chronic pain experience such nervous system changes as more pain signals, or nocioception, coming into the brain, and a brain that needs fewer signals, or has a lower threshold, to register pain. As a result:

• Sensations are more intense.

• Pressure registers as pain. Even light touch can be noxious to someone experiencing chronic pain.

• Heat or cold register as pain. The free nerve endings that house pain receptors also respond to temperature changes.

• The protective response of guarding, or splinting, tightens muscles and aggravates pain.

• Inactivity to avoid reigniting pain brings less circulation and oxygen to soft tissues, which worsens pain.

Although acute pain serves an adaptive role, such as prompting a person to withdraw a hand from a burning fire, chronic pain has adverse effects on function and well-being.

The Challenges of Chronic Pain

Chronic pain is defined as pain in one or more regions that has not abated in three months3,4, although it can last for years, with no other diagnosis to account for the pain and including significant emotional distress or functional disability3.

Long-term pain patients might be taking a variety of medications and coping with losses in relation to work, family, health and quality of life.

Chronic pain is complicated and magnified by stress, decreased sleep, depression, doctor and hospital visits, side effects from medications and procedures, and poor coping skills3. Each factor can interact with pain to create a feedback loop that spirals pain intensity out of control.

For example, the chronic pain client might worry about health, their ability to perform on the job or contribute to the family, thinking such thoughts as, “What is wrong with me?” Worry, anxiety, and stress can increase tension and tightness in soft tissues and intensify pain.

When people experience unrelenting pain, it is difficult to get comfortable enough to sleep. Pain can also wake them from nourishing sleep. When the body cannot rest and renew, pain escalates.

Uncontrolled pain generates anxiety and depression about what the future may hold. With no way to make pain stop, it is natural to dread its resurgence. When pain cannot be attributed to a known cause, when a miracle cure does not pan out, or when medications or treatments create unpleasant side effects, depression and anxiety may ensue.

Depression and anxiety proliferate tension, which the body interprets as more pain.

Unrelenting pain leads to such poor coping skills as poor diet, skipping exercise, incorrect medication usage, withdrawal from friends or activities, irritability, and poor sleep habits. Such behaviors limit one’s self-regulating capacity and ability to withstand and bounce back from pain.

For example, when someone hurts, they shy away from or lack energy to engage in activities, even if such activities brought the person pleasure in the past.

Health care providers can add to suffering. Medical providers who dismiss chronic pain patients as drug-seeking or psychosomatic by saying something like, “It’s all in your head,” or non-compliant when they ask questions or insist on being heard, only make pain worse.

Likewise, a massage client might feel minimized when a massage therapist continually interrupts, avoids eye contact, or constantly looks at their watch or toward the door. Insisting on an agenda, or on fixing, denying choices, and diminishing the person’s efforts to get well are other ways to inadvertently disrupt the healing process.

Your client might be recovering from a failed treatment, an overly demanding regimen, an invasive procedure, or adverse side effects.

3 Chronic Pain Situations: A Comparison

Chronic pain presents many challenges to massage clients and their therapists. To illustrate these challenges, let us compare three situations where the same precipitating event—tripping over a box—instigates very different conditions and considerations for massage.

In Case #1, we have a client with no previous history of ongoing pain. Case #2 is a client with past pain who experiences a symptom flare. Case #3 is a client who has had a long history of uncontrolled pain when he trips over the box. In all cases, the client has had the appropriate x-rays to rule out broken bones and approved for massage by their doctor.

Case # 1: Acute Pain

Chris trips over a box at home. The fall results in a twisted ankle and a scraped knee.

Chris is irritated at the person who left the box in his way and concerned about whether the ankle injury will interfere with driving to work the next day. There is some spasm in the ankle and lower leg.

In this case, Chris’s pain includes:

• Injury sustained by tripping over the box.

• Irritation.

• Some concern.

• Localized spasm in the ankle and lower leg.

Massage considerations:

• Massage proximal to the injured region to encourage blood flow and oxygenation to the area while removing dead white blood cells and debris created by the acute inflammation response.

• Massage the other side of the body, which is now compensating for muscles guarding the hurt.

• PRICE (protect, rest, ice, compress and elevate), which is the standard treatment for acute inflammation and injury.

• Additional considerations for these factors suggest adjustments for over-the-counter or prescription medications that Chris may have been prescribed to stop the pain-spasm-pain cycle.

Case #2: Chronic Pain Flare

At the time Jo trips over a box at work, she already has a history of low back pain and back surgery over the past five years. The fall results in a twisted ankle, scraped knee and pain radiating from the low back down the injured leg.

Jo is angry at the person who left the box in her way and anxious because her last fall incurred two weeks of bed rest followed by surgery. Jo has little sick time accrued and cannot afford to miss work.

In this case, Jo’s pain includes:

• Injury and a flare of chronic pain.

• Jo is truly angry when she remembers two weeks lost pay the last time she fell.

• With her history, Jo has clear anxiety about anticipated pain and suffering.

• Because past pain trained Jo’s body to detect danger, more pain receptors are activated at a lower threshold, so pain and spasms radiate over a larger area.

Massage considerations:

• Apply gentler massage to a smaller area, as tissues in flare are more sensitive to pressure. Still massaging proximal to injury, but the locally contraindicated painful area has grown.

• Continue PRICE and address compensating muscles, being aware that Jo’s sensitivity response may be less accurate because of NSAID use.

• Within the context of an intake, determine if Jo is taking additional prescriptions (painkillers) or self-medicating to dull tissue sensitivity.

• With flare, use cool applications instead of ice, because Jo’s nervous system may be too raw for traditional hydrotherapy.

Case #3: Chronic Pain Out of Control

At the time he tripped over a small box left on the sidewalk, Sam had a 20-year history of low back pain, fibromyalgia and multiple back surgeries. Relief from the last surgery lasted less than one month.

Sam is experiencing extreme burning down the low back into the buttocks, leg and foot after the fall.

Sam is very angry, and his anxiety has escalated to a state of panic. After the last fall, the ensuing pain led to a five-day hospital stay. Since then, he has been off work and his pain has never been fully controlled.

In this case, Sam’s pain includes:

• Injury plus a flare of old pain that is now out of control.

• Sam is extremely angry, remembering the hospital stay and how much his pain escalated after his last fall.

• Sam is experiencing panic over anticipated pain and suffering.

• Sam is depressed because of the situation, but also because depression and chronic pain register in the same part of the brain.

• Because Sam’s brain is already more attuned to danger, pain signals activate at an even lower threshold and pain radiates farther.

• Past pain experiences reduced Sam’s blocking signals to those rampant pain messages.

Massage considerations:

• Sam might be now so sensitized that he cannot stand touch, Pressure is felt as pain.

• In addition to NSAIDs and prescription analgesics, Sam could be taking anti-anxiety, anti-depressant, and possibly even anti-seizure drugs, which all have side effects and additional warnings. The massage therapist will know what medications any client is taking after completing a thorough intake.

• Massage therapists might have to rely on lighter or off-the-body modalities, diaphragmatic breathing techniques, and guided imagery for relaxation.

• Don’t blame the sufferer or diminish your efforts. Sam might be cranky, irritable, moody and sleep-deprived. He might vent, and pain reductions could be short-lived. A comforting presence, patience and persistence will go a long way toward making Sam feel at ease.

When Your Client Presents with Pain

• Create a safe environment; listen to your client.

• Believe your client. Do not label them as having victim consciousness or suggest that the pain is all in their head.

• Incorporate critical thinking. What works for acute pain might not be sufficient for flares or out-of-control chronic pain

• Use more conservative strokes and observe pressure and site restrictions.

• Give options and offer choices.

• Encourage efforts to get well.

• Encourage such pain-free movements and activities that increase quality of life as holding a grandbaby or turning the neck to see a rear view while driving.

• Coach relaxing breaths and suggest relaxing images within the session.

Above all, don’t shy away from massaging people who are experiencing acute or chronic pain. Massage can make a huge difference in their quality of life.


1. Rikard SM, Strahan AE, Schmit KM, Guy GP Jr. Chronic Pain Among Adults—United States, 2019–2021. MMWR Morb Mortal Wkly Rep 2023;72:379–385. DOI: Accessed 7/26/2023

2. AMTA 2023 Massage Profession Research Report. Accessed 7/26/2023

3. Raja SN, Carr DB, Cohen M, Finnerup NB, Flor H, Gibson S, Keefe FJ, Mogil JS, Ringkamp M, Sluka KA, Song XJ, Stevens B, Sullivan MD, Tutelman PR, Ushida T, Vader K. The revised International Association for the Study of Pain definition of pain: concepts, challenges, and compromises. Pain. 2020 Sep 1;161(9):1976-1982. doi: 10.1097/j.pain.0000000000001939. PMID: 32694387; PMCID: PMC7680716. Accessed 7/27/2023

4. Merskey, H., & Bogduk, N. et al. Classification of chronic pain and definitions of terms. Seattle: IASP Press. 1994; e2: 213.

5. Mifflin KA, Kerr BJ. The transition from acute to chronic pain: understanding how different biological systems interact. Can J Anaesth. 2014 Feb:61(2):112-22. doi: 10l1007/s12630-013-0087-4. Epub 2013.PMID:24277113. Accessed 7/27/2023

Marian Wolfe Dixon

About the Author

Marian Wolfe Dixon, LMT (OR #3902), is an NCTMB Approved CE Provider (#769). She completed master’s degrees in psychology and health education and a post-doctoral research fellowship with the National Institutes of Health. Working professionally as a licensed massage therapist and health educator since 1992, she is the author of “Myofascial Massage,” “Body Mechanics and Self-Care Manual” and “Bodylessons.”