A massage therapist’s typical day often involves seeing clients who present with a wide variety of complaints, from plantar fasciitis to tension-type headaches.

To effectively address these various complaints, a deep understanding of the functional anatomy and pathology of each condition is necessary.

Yet, stepping back, the common denominator of all of these presentations is pain. We, as therapists, must also educate ourselves about the general principles of pain mechanisms in order to effectively serve our clients.

As the science of pain continues to emerge, it is very clear that what we call pain is a highly complex subject. The title of this article refers to the mystery of pain, rather than solving the puzzle of pain.

It is a crucial distinction. In a puzzle, you are missing something; once you locate the missing piece, the puzzle is solved. In a mystery, everything necessary to solve the problem it is in front of you, it just takes a deeper understanding to come to resolution. Pain is much more mystery than a puzzle.

In the very complex and layered subject of pain, I will choose three points of emphasis that will have immediate application for your massage therapy practice. These principles are attribution, validation and empowerment.


In the phenomenon of pain, it isn’t the experience of discomfort that is so disturbing, it is often the perceived meaning of the sensation we feel. For example, if a client whom we’ll call David overextends himself helping a friend move into a new house, it would not be unreasonable for his back muscles to complain the next day.

While he is in pain, the cause and therefore the meaning of his pain is clear, as well as what the projected timeline might be.

David is not worried about deeper implications. On the other hand, if his back pain came on insidiously, tying the onset to a specific cause is not really possible. David’s mind is left to wonder about the possible implications of this new pain. Are there arthritic changes in the spine?

Perhaps underlying degenerative changes in the disc? Is this stenosis? Could it be something far worse? Is this the beginning of a lifelong struggle with back pain?

While there are many low back pathologies that result in pain, imagine now that David sees a massage therapist and experiences significant relief after two or three sessions. What must he be thinking now

In all probability, David assumes that his pain was due to muscular causes, since muscular treatment was so helpful. In light of the other scary scenarios David had imagined, muscular discomfort is certainly the most benign.

Knowing his discomfort is due to muscular causes will immediately put his mind at ease, which will also lessen the experience of pain. If there is one emotion the exacerbates the experience of pain, fear is it.

Knowing that the pain is likely muscular can be important in lessening his fear, thus lessening the experience of pain even more.

Another benefit of attributing pain to muscular causes involves the phenomenon of kinesiophobia, the fear of movement. If David attributes his pain to degenerative processes in his spine, he is likely to limit movement to avoid further damage. If it hurts to move, he decides not to move until the pain goes away.

This belief can have unfortunate consequences as most of the research shows the more you move, the better the outcome. (The days of bed rest for back pain have themselves been put to bed.) Part of this beneficial effect is due to a process called descending inhibition.

During continuous movement, the brain inhibits the experience of pain, probably as an important survival mechanism. If you were running to escape from a lion, complaints from your legs about the excess demand isn’t exactly helpful for survival.

The brain inhibits pain messages until the danger has passed — which is how a soldier can be wounded and not realize it until the battle is over.

We all experience this at a lower level when beginning to exercise; our body often initially complains, then the discomfort subsides after we get further into the workout.

As descending inhibition is a product of movement, a significant benefit of massage therapy may be helping people feel more comfortable being active; it is hard to move when movement is painful. The more comfortable it is to be reasonably active after a bout of pain, the faster the recovery.

Mechanical Pain

It is important to note that musculoskeletal conditions are under the domain of mechanical pain; that is, pain that is made better or worse with movement or position. It is vital to ask each client if there is some activity or position that makes his or her discomfort better or worse.

If not, it points to causes other than musculoskeletal and the client should see his or her physician to explore this further.

In my career, this distinction has uncovered some life-threatening conditions. While there are always exceptions, it is wise to err on the side of caution.


Unfortunately, there is a long history of health care providers finding new ways to invalidate people who hurt. One only has to look at the history of pain with regard to women to make that abundantly clear. (The word hysterical might serve as a good example.)

Many massage therapists have heard countless stories from clients who felt that no one actually listened to them or believed that their unexplained pain was real. Invalidation makes the experience of pain far worse and is most devastating when the client begins to doubt herself.

If I can’t see it, you don’t have it

There is a strong belief that diagnostic imaging is the gold standard; everything that could possibly be wrong can been seen, identified, and therefore eliminated. Many possible causes for pain cannot be seen on a diagnostic image, but they are no less real.

After two or three providers find nothing, the client begins to get the message that the pain is “in my head.” This invalidation can be devastating; he or she feels bad, and now feels bad for feeling bad.

Imagine this client now under the hands of a knowledgeable massage therapist, who is able to replicate the pain via careful palpation. How many times have we all had this happen? I’ve had clients burst into tears after I replicated their pain with my hands.

“I knew I wasn’t crazy,” one client exclaimed.

This is a powerful moment of validation — and one that is often distinct to the power of touch. The client often has a vague notion of the pain location, but having a therapist place a finger directly on the offending area is incredibly validating. That validation alone is a powerful step toward pain resolution.


If clients see pain from the puzzle perspective, they continually search for the missing piece that will miraculously solve their pain. This can often lead to an endless parade of health care practitioners, each leading to disappointment and disillusionment.

When you understand pain from the mystery perspective, it becomes clear that the pain experience is truly multifactorial. To use a baseball analogy, you aren’t trying to win the game with a home run, but a series of successive singles.

Research in pain shows the importance of sleep, nutrition, movement, dietary influences, attitude and a host of other factors. Initially, this can be confusing, bordering on overwhelming for the client.

Seen in another perspective, however, it means there are many options for affecting pain. The more ways you address pain, the more successful you will be in lessening it. Even small improvements in multiple areas can have a very significant collective effect.

When clients view pain from the puzzle perspective, they often feel like someone else holds the key to solving their problem. When the client understands pain as multifactorial, that also means there are many fronts on which to make a difference.

This gives the client a sense of empowerment, a sense there are things they can do now to make a difference in the way they feel. That alone is powerful medicine.

Massage therapy is ideally suited as a powerful strategy to reduce pain. Through effective massage therapy techniques, the initial decrease in pain may give the client the needed hope and inspiration to pursue a more active role in pain management.

Massage therapists have the great luxury of spending ample time with their clients, during which education about pain can take place. Experientially, a great massage resembles a guided tour of one’s own anatomy and that process of self-discovery often leads to a greater respect and appreciation for the wisdom of the body. This is likely to lead to better lifestyle choices.

Lastly, it is important to remember that clients who present with pain come to us at a time when they are often most vulnerable, both physically and emotionally. While helping those who hurt is a great responsibility, it is our great honor and privilege to do so.

About the Author:

Douglas Nelson
Douglas Nelson, LMT, BCTMB

Douglas Nelson, LMT, BCTMB , is president of the Massage Therapy Foundation, which advances the knowledge and practice of massage therapy by supporting scientific research, education and community service. Nelson began his career in massage therapy in 1977 and maintains an active clinical practice. He has served as a neuromuscular consultant to NBA and NFL teams, as well as high-level musicians. His book, The Mystery of Pain, was publishing by Singing Dragon in 2013. Look for the Massage Therapy Foundation’s first, every-issue column, “Massage Research,” beginning in the August 2019 print issue of MASSAGE Magazine.