Massage therapists are witnesses to clients’ pain perception, evidenced by armoring, vocalization and other reactions from the table.

Massage therapists are witnesses to clients’ pain perception, evidenced by armoring, vocalization and other reactions from the table.

Massage therapy has been slowly gaining greater acceptance as an intervention for pain, stress, symptoms of anxiety and depression, and other medical concerns that tend to persist over time.

Because pain is one of the primary reasons people seek massage therapy1, 2, I encourage massage therapists to learn about current pain science, which is based on a rapidly growing mountain of research. Understanding the biopsychosocial models of pain and therapy, and how those are applicable to massage, is incredibly helpful throughout the process of establishing rapport, intake conversations, hands-on work and client education.

Some quick background: the word biopsychosocial was coined by George Engel, MD (1913–1999) in 1977 to encourage medical practice to become more patient-centered and reject the prevailing biomedical model.3 It didn’t have a great impact until John Loeser, MD, introduced his onion-skin model of pain and suffering in the 1980s.4,5

“The biopsychosocial model is a broad view that attributes disease causation or disease outcome to the intricate, variable interaction of biological factors (genetic, biochemical, etc.), psychological factors (mood, personality, behavior, etc.), and social factors (cultural, familial, socioeconomic, medical, etc.),” wrote David S. Butler, PT, and G. Lorimer Mosely, Ph., in “Explain Pain Supercharged”: “The biopsychosocial model counters the biomedical model, which attributes disease to roughly and only biological factors, such as viruses, genes, or somatic abnormalities. The biopsychosocial model applies to disciplines ranging from medicine to psychology to sociology; its novelty, acceptance, and prevalence vary across disciplines and across cultures.”5,6

Examples of some factors and which biopsychosocial domains they are most frequently associated with:

• Such ideas were not new, but in 1965 the Gate Control Theory, published by psychologist Robert Melzack, MSc, PhD (1929–2019) and neuroscientist Patrick Wall, DM, FRS (1925–2001), had opened new ways of considering how the nervous system might explain these and other factors.7

• By 1973, Melzack’s “The Puzzle of Pain” described the implications and limits of the Gate Control Theory.8

• In 1989 Melzack’s neuromatrix theory of pain provided a working model that continues to be used by scientists and clinicians around the world.9,10

Neural Networks in Pain Perception

A key concept in the neuromatrix theory is that the brain is a mass of neural networks. When stimulated, these networks combine to generate motor signals, sensations, physiological changes, etc. Habituated combinations of networks are referred to as neurosignatures. Thus, there could be neurosignatures for various types of discomfort, and they could bifurcate to produce both perception of such discomfort and related motor commands like bracing.

Science has revealed enormous neuroplasticity in the brain; neurosignatures are not unchangeable. Like graffiti tags, variations of neurosignatures (aka “neurotags”) compete for dominance. Action neurotags influence muscle activity, consciousness, and other output systems. Modulation neurotags affect how we experience sights, smells, proprioception, other sensations, prior experiences, familiarity, and implicit concepts. How therapists interact with clients influences which neurotags are stimulated to affect their experiences and responses.11

In 1973, anesthesiologist John J. Bonica (1917–1994) convened a group of pain researchers and clinicians to improve knowledge and treatment of pain, and the International Association for the Study of Pain (IASP) was incorporated in 1974.12 In 1979, the IASP formally defined pain and started an international, interdisciplinary effort to name and define many other pain-related terms.

These terms and definitions are revisited and updated. In July 2020, the IASP introduced a revised definition of pain for the first time since 197913,14:

Pain: An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.

• Pain is always a personal experience that is influenced to varying degrees by biological, psychological and social factors.

• Pain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons.

• Through their life experiences, individuals learn the concept of pain.

• A person’s report of an experience as pain should be respected.

• Although pain usually serves an adaptive role, it may have adverse effects on function and social and psychological well-being.

• Verbal description is only one of several behaviors to express pain; inability to communicate does not negate the possibility that a human or a nonhuman animal experiences pain.

In practice, we apply this definition of pain by recognizing that pain is a subjective and emotional experience influenced by a variety of factors; it isn’t always caused by tissue damage. Communication is helpful, and we need to listen carefully to how people describe their symptoms or dysfunctions.

Some clients may be unable to communicate their pain in typical ways, so we need to accommodate them. We can help people understand that pain can be a positive adaptive response—such as the pain that keeps us from touching hot surfaces—but too much for too long can have a negative effect.

Research is Catching Up to Pain Perception

Science is gradually increasing what we understand about pain perception, or what we feel and how we feel it. For example, proprioception is our ability to sense the position of our body in space relative to itself and its surroundings, and how that position changes. This is related to interoception, which is the ability to sense the internal state of one’s body. Having interoception doesn’t automatically mean that we can interpret it correctly or describe it to others, but it does contribute to our gut instinct, especially if “something just doesn’t feel right.”15

It’s important to pay attention to interoception, but we also need to understand that it may represent some neurotags that could trigger either a placebo or a nocebo response depending on context and prior experiences. Thus, evidence-informed clinical reasoning and sound assessment strategies are necessary complements that provide more consistent and reliable ways of determining which approaches are most likely to meet the needs of the massage client.

At the 2020 San Diego Pain Summit, Dave Walton, PT, PhD, presented research16 showing how the recovery of patients tends to be fairly predictable, with most following one of three different trends over time, and that those trends do not seem to be determined solely by the frequency or severity of exposure to physical trauma.16 The pre-existing stress response mechanisms within the client seem to play a large role in their long-term recovery, or lack thereof. Formal, validated assessment tools like the Traumatic Injuries Distress Scale17 can help indicate which clients are most likely to recover quickly.

Walton also presented research discussing:

• Sex and gender interactions can influence pain experiences and treatment outcomes.

• Sleep hygiene can help predict pain experiences.

• C-reactive protein in the blood does not predict pain severity.

• The more threatened people feel as a result of their trauma, the more it predicted distress and interference with daily activities.

• Hair reflects cortisol levels over time and is strongly correlated to the Traumatic Injuries Distress Scale assessment tool.

• People with chronic pain tend to have differences in key immune and inflammatory markers in their blood, and there is correlation with pre-existing psychopathology.

• It may become possible to develop blood tests to determine which people are most likely to recover quickly or slowly.

• Genetic testing is shedding light on which genes may contribute to increased risk of pain experiences and poor outcomes.

• Potential biomarkers for pain and likely prognosis that might be found in saliva, blood, and the gut microbiome.

Insight on Pain Perception

The use of better assessment tools than the old 0-10 pain scale has been addressed by hundreds of authors, educators and presenters over the past 20 years. There are dozens that have been developed, evaluated and validated in research and clinical practice. Each has different strengths, but all serve to provide some insight into pain and pain perception—and how these affect them.

The Brief Illness Perceptions Questionnaire, Traumatic Injuries Distress Scale, Neck Disability Index, a good body diagram and many other assessment tools are available free of charge.17 Used well, these facilitate communication, trust and therapeutic alliance between massage client and therapist, and facilitate effective treatment planning.

The use of client education and communication skills to address psychosocial factors has evolved greatly. These can be highly scripted one-session group treatment classes like the Empowered Relief program developed by Beth Darnall, PhD, of Stanford University. The highly scripted nature of the program enables the training of effective class instructors over the course of a weekend.18

When working with individuals, training in skills like motivational interviewing19 and pain science (i.e., “Explain Pain” classes20) facilitates personalized and meaningful dialogues that build and strengthen relationships and increase odds of successful outcomes.

In learning about these topics, we gradually learn to think differently about what we do and the choices we make. Courses that combine current pain science with manual or movement therapy informed by that information (“Dermoneuromodulation”21 or “Reconciling Biomechanics with Pain Science”22 as examples) can make it easier to understand how the new information will be immediately useful in massage therapy.

The potential is amazing. This brief article barely touches the surface of what massage therapists can learn and use regarding pain perception and pain science to help their clients, set themselves apart from their peers and be successful.

About the Author:

Jason Erickson, BCTMB, CPT, co-owns and practices at Eagan Massage Center. A former chronic pain patient, Erickson is an internationally recognized continuing education provider teaching classes on pain science, dermoneuromodulation, sports massage, research literacy and more. His articles and podcast appearances are widely featured. His articles for MASSAGE Magazine include “Placebo vs. Nocebo: What Role Does Each Play in Massage Therapy?”


1. Erickson J. Build Your Practice on a Foundation of Evidence. Massage Magazine. Nov. 2019; Issue 282; pp. 20-23.

2. American Massage Therapy Association website. 2020 Massage Profession Research Report page ( Accessed Aug. 20, 2020.

3. Engel GL. The need for a new medical model: a challenge for biomedicine. Science. 1977;196:129–36.

4. Loeser, J.D. Pain as a Disease, Chapter 2. Handb. Clin. Neurol. 2006; 81; 11-20.

5. Moseley GL, Butler DS. Explain Pain Supercharged. Neuro Orthopaedic Institute Group Publications. 2017; pp 13-14,

6. Biopsychosocial model. Wikipedia. Accessed 24 January 2017.

7. Katz J, Rosenbloom BN. The golden anniversary of Melzack and Wall’s gate control theory of pain: Celebrating 50 years of pain research and management. Pain Res Manag. 2015; Nov-Dec; 20(6): 285–286.

8. Melzack R. The Puzzle of Pain. Basic Books. 1973.

9. Melzack R. Phantom limbs, the self, and the brain (The D.O. Hebb memorial lecture). Canad Psychol. 1989; 30:1–16. ( Accessed Aug. 20, 2020.

10. Melzack R, Katz J. Pain. WIREs Cogn Science. 2013; 4:1–15.

11. Moseley GL, Butler DS. Explain Pain Supercharged. Neuro Orthopaedic Institute Group Publications. 2017; pp 19-31.

12. International Association for the Study of Pain website. About page. ( Accessed Aug. 20, 2020.

13. International Association for the Study of Pain website. Terminology page ( Accessed Aug. 20, 2020.

14. IASP Announces Revised Definition of Pain. International Association for the Study of Pain website ( Accessed Aug. 20, 2020.

15. Walton DM, Elliott JM. Musculoskeletal Pain – Assessment, Prediction, and Treatment. Handspring Publishing. 2020; pp 11.

16. Walton DM. “Blood, Spit, Hair, and Poop … And Other Things Embracing Complexity in the Genesis of Chronic Pain” presentation. 2020; San Diego Pain Summit.

17. Pain and Quality of Life Integrative Research Lab website. Clinician Resources page ( Accessed Aug. 20, 2020.

18. Empowered Relief. Stanford University website ( Accessed Aug. 20, 2020.

19. Motivational Interviewing website ( Accessed Aug. 20, 2020.

20. Neuro Orthopaedic Institute Group website. Courses page ( Accessed Aug. 20, 2020.

21. Dermoneuromodulation website. Home page ( Accessed Aug. 20, 2020.

22. Reconciling Biomechanics with Pain Science website ( Accessed Aug. 20, 2020.