Massage and therapeutic touch have been used for thousands of years, and until recently we thought we pretty much knew what was going on! Therapists have been describing to patients that their skillful manipulation of the tissues of the body would cause any and all of the following changes to occur;
- Releasing Trigger Points
- Myofascial Release
- Increase Circulation
- Decrease Stress
- Increase Muscle Enzyme activity
- Break down scar tissue / adhesions
Over the last 5-10 years there has been a growing body of scientific research into all types of manual therapies and comparing their specific effects to the effect of placebo or sham interventions, and compared to no treatment at all. This large body of evidence now calls most of these physiological effects into question. The following blog post is an expansion on a Professional Development session that was held at Hills Physiotherapy so that we know that our therapists are all practicing with the most up to date and evidence based techniques, and the most truthful and accurate explanations for exactly what it is that they are doing to you, their patients.
Lets examine the above claims one by one and see which ones stack up, and which ones don’t.
Releasing Trigger Points
This has been covered in a previous blog post so I won’t spend too much time on it here. Suffice it to say that the existence of these little muscle nodules has never been proven in rigorous scientific testing, and all of the studies that show clinical benefit from treating them actually start with the widely accepted definition of a trigger point – accepting their existence without any supporting evidence. By showing that treating them does have clinical benefit is not the same as proving they exist, when any number of other explanations for the patient’s improvement in condition could be offered, many with more credibility and evidence to support them. If we can’t find them with Ultrasound, MRI, biopsy, EMG, or even reliably agree (between expert therapists) where they are on a given patient, we really have to throw out this explanation as being untruthful, an unhelpful from here on.
This was also covered in the blog post linked in the paragraph above, as were the studies used to disprove it. The central conceit here is that by applying pressure from outside the skin, the therapist will deform / stretch / or “release” tight spots in a patient’s fascia (the tough connective tissue that encapsulates muscle tissue), and thereby relieve their pain. Two major problems – fascia hasn’t been proven to be involved in the pain experience (no real nociceptive output), and we can’t deform it even if we try. The two major studies that confirm the second point show that a) As we put pressure on the skin it just slides over the fascia with negligible friction, so we just can’t apply a shear force to stretch it, and b) the other study showed that the force required to stretch fascia by even 1% is beyond human capability to apply.
To a degree, the jury is still out on this one, but the evidence is leaning towards busting this concept. There is good evidence to show that skin circulation increases (but since we can see the skin flush pink during treatment we don’t really need proof), however it has always been taken as gospel that we are increasing the circulation within the muscle tissue below the skin, and the evidence for this is really not that good. Some studies fail to reach significance (the result could be from random chance, or from the treatment), while others report positive outcomes, but have error margins that make their results meaningless (ie showing an increase in blood volume within the muscle of about 14units, but having an error margin of +/-135units). It would appear that there is no strong evidence to suggest that externally applied massage can influence deeper tissues blood circulation.
Surely, surely this one is unshakable. ANYONE who has been and had a massage will tell you how much better they felt, how floaty they were afterwards, how it melted away all their stress. On a side note, have you ever had a friend go to a massage therapist and NOT be told they hold all their stress in their shoulders? Unfortunately, the *feels* you get from a massage are only a psychological construct, which may have some lasting effect on mood. Actual stress is best measured by the level of circulating stress hormones in your blood or saliva. In some very well designed and large studies testing the effect of massage on salivary cortisol levels, strong evidence was found for reduction of cortisol and heart rate during the massage, but no evidence for sustained effect even at 2hrs, 12 hrs, 24 hrs etc. So ultimately, massage reduces stress while you’re having it, then you go back to life.
Increased Muscle Enzyme activity
This piece of wisdom probably makes sense if the “increasing circulation” axiom held true. Which it doesn’t. The idea being that by exciting the biochemistry of the muscles manually by alternating pressure, the enzymes and hormones involved in muscular function get some sort of boost. This is probably an easy enough thing to study, given modern technology. Massage, biopsy, control, biopsy. However, research in this space has been confined to small numbers of patients (low power) and in most cases the primary outcomes focussed on far, far too many variables, meaning that the ability to generalise the results to a larger population are negated. Most studies on humans need hundreds of subjects to reach statistical power for a single primary outcome (like the effect of an intervention on pain, or a single enzyme), however the research in this area seems often to have 10-40 subjects, and tests for 8-15 different blood variables, which means any trends in data are unlikely to be anything other than chance or bias related. While we can’t say with certainty that this is NOT true, we can say that there is no evidence to support it being true.
Break down Scar Tissue / Adhesions
This is an area that really has very little research at all. In cases where a question lacks scientific enquiry, we fall back on whether it is biologically plausible (does it actually make any sense when we look at it). The fact is, we NEED scar tissue to heal damaged tissue. Once this tissue has consolidated it becomes strong collagen fibre, just like fascia really. We’ve looked at fascial release as a concept above and found that it is impossible, so it’s likely that scar tissue is not able to be manipulated, deformed or released. It IS plausible that treatment during the early phases of healing can reduce excessive scarring by physically displacing the inflammatory and blood products responsible for promoting and producing the scar, but after the first 14 days or so manual therapy is unlikely to have an effect.
So is there any evidence for massage being helpful at all?
A systematic review in 2016 analysed 3678 papers, 67 of which were high quality (methodology, pre-trial registration, sham controlled – all the things good scientists do to try to remove their own bias from the results and analysis). Pooled results compared the effect of massage with a sham treatment, or active comparitor on the following outcomes; Pain, Function / Activity, and Stress / Mood / Quality of life.
Results showed the following;
- Strong effect vs no treatment on Pain
- Weak positive effect vs sham and other intervention for pain
- No effect on function / activity
- weak but positive effect on psycho-social factors (stress / mood / quality of life)
So what is it that’s really happening here?
Touch is (for some) a powerful safety message. We know that Pain is a protector, and that the brain will decide to produce this protective output to change behaviour, based on the relative balance of danger and safety that it perceives at that moment (see this blog for more in depth discussion of this). In the professional, comforting environment of a massage therapist’s treatment room, the safe and purposeful touch of hands on the painful body part will cause a patient’s brain to produce chemicals that trickle down into the spinal cord and block the nociceptive (danger) messages coming from the tissues. It is not the THERAPIST that causes the muscles to “release” or soften, it is the patient’s own brain that reduces the protective drive and relaxes the protective spasm.
There is strong evidence to show that the “Therapeutic Alliance” (your trust in your therapist) has a strong effect on improved outcomes in pain conditions (Low Back Pain, Fibromyalgia). This relationship is multi-factorial obviously, but basically – Do you like them? Do you trust them? Do you think they will help you? If you answered yes to all three, then you’re probably right. And the reason you’re right, is that you answered yes to the three questions, not necessarily what they magically do with their hands.
Regarding what they do with their hands (or we, I should say, since I’m a manual therapist too) – surely it’s not just about the brain? The relationship? Psychological factors? Well, we know that we’re not actually manually releasing muscle spasm (the brain does that) or releasing fascia (impossible), but touching the skin is still going to have physiological effects. The brain is an inhibitory organ, with more than 200 times more neurons descending to the body, than arriving from the spinal cord (brain is boss, controls all). This means that by touching the skin and providing input (sometimes painful) we can trigger Descending Noxious Inhibitory Control. This is basically your brain’s way of cutting out some of the noise. If it decides some of the input coming in from the world is unnecessary, it sends down messages to damp down the noise. If you have a sore shoulder, and someone rubs it, your brain experiences safety and comfort and reduces the need to protect, and therefore reduces pain and muscle guarding.
Take Home Messages
- You are not a Meat Robot – your experience of pain is NOT a direct result of things happening in your body, and the benefit you get from massage is NOT due to direct physical effects on those tissues. Think about the skin, nerves, brain, and the experience, not just the “knots”
- Do you really have knots? Do you really hold stress in your shoulders? Are you out of alignment? Ready for a bullet? Past your use-by date? These metaphors convince your brain that it needs to protect you more, and so you will have more pain.
- Try to think about yourself, and talk about yourself in more positive language – Long and lean, gliding and sliding, normalising movement, softening pain (not killing!)
- It is YOUR brain that is releasing the muscles during massage, not your therapist (but if you like them, then that helps)
Hills Physiotherapy strives to provide not only the best Allied Health experience available, but also to stay at the forefront of Evidence Based Practice. If you are seeing a therapist who is still trotting out the old chestnuts “You hold your stress in your shoulders”, or “Gee, you have knots everywhere” then maybe you need to consider seeing someone who can not only give you an amazing therapeutic experience (ie a bloody great massage) but also can explain to you what they are doing in a way that is much closer to the truth. We owe you that much, don’t we?
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