Deep tissue massage needs a modern narrative

Key takeaways: 

• There is no consistent or commonly accepted defintion of “deep tissue massage.” Different practitoners, schools, and businesses tend to have different definitions.
• Deep tissue massage is different from Swedish massage by how the massage is delivered, the clients’ goals, amount of pressure, and fewer amounts of oil or lotion used.
• The strongest scientific evidence of deep tissue massage benefits to date are reductions in depression and anxiety and short-term neck pain relief. However, deep tissue massage has been found to be not significantly better than exercise for chronic neck pain.
• Deep tissue massage does not break up scar tissues, fascia, and muscle adhesions because research has shown that it takes a tremendous amoutn of pressure to deform fascia (and similar connecdtive tissues) by 1%.
• A review of what to expect from a deep tissue massage session if you’re a first-timer.
• Questions you should ask your massage therapist in your first session.

Deep tissue massage sessions typically focus on one area of your body using firmer or more sustained pressure, which is quite different from the full-body flow of a relaxation massage, like Swedish.

It uses a number of methods that clients often request who are looking for injury rehabilitation, joint mobilization, or treatment of specific muscle and joint problems. These methods tend to be very popular among athletes for treating sports-related issues and for those who deal with chronic pain.

Modalities that often use a “deep tissue” approach include sports massage, shiatsu, Thai, lomi lomi, and Balinese style massage, and other offshoots.

Definition

You often see the term “deep tissue massage” on the service menus and websites of massage businesses. However, there’s very little consistency to how this is defined among massage schools, massage therapists, spas, and wellness clinics.

Physical therapists Yogev Koren and Leonid Kalichman of Ben-Gurion University of the Negev in Israel wrote in a 2017 editorial that there is“no commonly accepted definition of deep tissue massage in the [scientific]  literature.

For example, they cited the Australian Association of Massage Therapists’ (AAMT) deep tissue massage definition as [focusing] on the deeper layers of muscle tissue. It is designed to reach the deep sections of thick muscles, specifically the individual muscle fibers.”

However, massage therapist and author Art Riggs defined deep tissue massage as “The understanding of the layers of the body, and the ability to work with tissue in these layers to relax, lengthen, and release holding patterns in the most effective and energy efficient way possible within the client’s parameters of comfort.”

“This definition may encompass the full concept of the method, but it is too open for interpretation to serve as a baseline definition for research,” Koren and Kalichman wrote.

Swedish massage vs. deep tissue massage

Both Swedish and deep tissue massage share fundamental principles and only differ in their intention, pressure application, and focus.

Deep tissue massage often incorporates forearm and elbow moves applied with varying pressure to a targeted area. Therapists may maintain this position from 30 seconds to two minutes—sometimes even longer depending on your preference and condition.

Stretching—either actively or passively—can also be added into a deep tissue massage, which is a predominant element in athletic treatments, lomi lomi, Thai, and Balinese style massages.

Stripping, or deep friction pressure, can also be applied with the therapist’s knuckles, elbows, forearms, or thumbs. Deep tissue massages don’t always include oil or lotion and can be performed while you’re fully clothed.

Meanwhile, Swedish massage is the foundation of Western-style relaxation massage.

The main massage strokes of Swedish massage are:

• Effleurage
• Petrissage
• Friction
• Tapotement
• Vibration

These techniques can be arranged in many ways according to each therapist’s preference, which gives a more unique and artful approach to the bodywork. Strokes can be applied with fingers, palms, elbows and forearms at any level of pressure.

Swedish massage sessions are generally performed by applying oil or lotion onto your skin in a flowing, continuous manner with steady pressure applied across the entire surface of the body.

The pressure used is typically light to moderate (based on your preference) and offers attention to the whole body for a general relaxation experience. The massage therapist will start with Swedish massage to allow you to get used to their touch, warm up the tissues, and hone in on a specific area.

Trivia: It’s a common misconception that Swedish medical-gymnastic practitioner Per Henrik Ling created this concept model of modern massage in the early 1800s.

It was actually Dutch doctor Johann Georg Mezger who created the application of five specific strokes that are now known as Swedish (classic) massage. The terms were named from French terminology by Dr. Mezger due to the rising popularity at the time for the French terms masseuse and masseur.

Benefits

Deep tissue massage shares many similar benefits with other types of massage:

• Short-term pain relief
• Reduces anxiety and depression
• Increase relaxation

The sense of touch on its own can be very powerful, and the complexity and specialization of the nerve fibers in the skin shows that humans are built to receive rich sensory experiences. The ability to have pleasant touch coded into the nervous system can allow for new ways to offer pain relief.

The most evidence-based benefit to deep tissue massage is that it reduces anxiety and depression, which can be standalone conditions or be symptoms of other illnesses and chronic pain issues.

Psychologist Christopher A. Moyer, who specialized in conducting meta-analyses in massage therapy, concluded that massage treatments result in “sizable reductions of depression” and “significantly reduce state anxiety.”

Considering that anxiety and depressive disorders are prominent health concerns globally, having complementary therapeutic options in healthcare can be very welcome.

Like other types of massage, deep tissue massage has been to provide short-term pain relief. In a 2020 study published in Musculoskeletal Science & Practice, deep tissue massage and exercise/massage sessions were found to improve subacute and chronic neck pain at seven weeks and 26 weeks and at seven weeks and 12 weeks, respectively. These sessions were compared with a control group who were given only pain relief advice.

However, at the 12-month follow-up, these sessions were no better in pain and disability improvement than the control group.

Deep tissue massage myths

There are three major common myths about deep tissue massage. These include:

• More pressure is better for you
• Breaking up fascia, scar tissues, and muscular adhesions
• Releasing toxins from the muscle tissues

Adherence to these myths is not only unethical but also potentially dangerous to clients.

Myth #1: Deeper pressure is better for pain relief

The wellness industry trope of “no pain, no gain” has been a longstanding and inaccurate ideology. Some clients may feel that there’s a certain badge of honor that comes with being able to withstand large amounts of pressure in a massage. Others may feel that it is expected with deep tissue work. This simply is not the case.

Everybody has a different threshold for both what’s considered their level of feeling soothed and pain. Pressure preferences can also change  based on the area of the body. For example, shoulders may be able to handle more pressure than the calves.

Applying too much pressure can create an adverse reaction in the body, like tensing up, but the right amount of stimulation can elicit a relaxation response. A painful response may cause anxiety and tension to spike in the nervous system and negates any beneficial effects of the massage. In some cases, bruising and tissue damage can occur.

Alternative

Rather than looking at deep tissue massage as a direct manipulation of muscles and tissues, look at massage from a neuroscience perspective.

Massage uses direct touch to the skin to engage the nervous system through its network of skin receptors. Human skin has about 1,000 nerve endings per square inch and is rife with four different types of mechanoreceptors that receive information about touch, pressure, vibration, temperature, and other stimuli.

Depending on the type of touch and duration of compression, they transmit information at different rates. When a massage therapist applies pressure, signals are transmitted to your brain and changes how you sense your body.

Nociceptors are another type of sensory neurons that detect potentially dangerous stimuli at the skin level.

According to the research of Dubin and Patapoutian in 2010, “Normally, nociception and the perception of pain are evoked only at pressures and temperatures extreme enough to potentially injure tissues and by toxic molecules and inflammatory mediators.” In short, nociception is a sensory process that can lead to pain.

When a massage therapist applies the right pressure and stimulation to a client, this can result in a positive sensory experience, reduction in stress, and an overall calming effect.

Myth #2: Deep tissue massage breaks up scar tissues, fascia, adhesions

Deep tissue massage cannot break scar tissues or fascia or deform muscle adhesions in any way to alleviate pain. Although well-packaged in massage marketing, these ideas are often subject to scientific studies that are flawed or rife with cherry-picked evidence.

Fascia is a type of collagen-dominant, fibrous connective tissue found throughout the body in bands or sheets that separate muscles and attach or enclose the internal organs. It’s one of four types of connective tissues found in the body, and together, these tissues serve to protect, insulate, bind and support the internal organs, store fuel reserves (in the form of adipose cells), and transport substances within the body.

The Fascial Distortion Model that was developed by Dr. Stephen Typaldos in 1991 was the springboard for the myth that fascial deformations are the cause of most muscle pain. The model suggests that these issues can be fixed with varying degrees of force to the fascia itself. This has led to several false claims by a number of agencies that fascia can be melted, rolled, and/or manipulated with various specialty tools and techniques.

Due to its densely fibrous nature, fascia is so tough that surgeons need scalpels to be able to cut through it. The idea that it can easily deform with touch is implausible and many studies indicate this.

One such study by Chaudhry and colleagues (2008) indicates that only with incredible forces would fascia be able to be manipulated in the way that many proponents claim. If deep tissue massage was able to be applied with the force necessary to shear 1% of fascia, it would have to be about 2,000 pounds of force—literally a crushing pressure to the body.

Alternative

Even if fascial imbalances were responsible for creating body pain, receiving a deep tissue massage would not be able to fix them. Instead of looking at fascia, focus the mechanoreceptors that are responding to the manual pressures applied.

The same goes for the ideas of scar tissues, muscle adhesions, muscle knots, and trigger points. Although the sensations and localized pains are very real to clients, scar tissue and “stuck” tissue do not spontaneously occur without prior surgery or injury.

A discussion of fascial plasticity by Schliep (2003) proposed that stimulation of various mechanoreceptors may create palpable changes in the tissues that may be perceived by massage therapists or the client. This is not an unwinding or change in the fascia. Instead, it’s the effects of the nervous system that touching skin may have created impulses that are sent to the brain and interpreted with neural responses that likely create the illusion of unwinding.

Many surgical studies have indicated that there can be post-surgical adhesions and scar tissue development after procedures due to tissue traumas. However, no studies exist that prove non-traumatic adhesions exist.

For example, Andersen et al. (2009) indicated in their muscle pain study that there can be touch-sensitive places within the body that do not correlate with any true muscular tightness or rigidity. This and other research indicate that tissue quality does not overlap with pain on a consistent, predictive basis.

If massage therapists cannot manipulate fascia or break down scar tissue in a deep tissue massage, what explains the sensations of “releasing” these tissues or the sensation of a “knot” in the muscle?

This can often be explained by a phenomenon called palpatory pareidolia, a neurologic event in which a vague stimulus (in this case, an unknown skin texture) is perceived as distinct and tangible. This is the same phenomenon that allows humans to see familiar shapes in clouds or religious figures in objects.

The human brain will attempt to fill in something familiar when it cannot fully interpret an impulse, sensation or visual cue. In massage therapy, this misinterpretation can lead to a certain magical thinking.

Myth #3: Massage releases toxins

Releasing toxins is one of the oldest myths of massage that is regularly resurrected no matter how much research surfaces to bury it.

The myth behind releasing toxins in massage claims that massage helps flush alleged harmful substances—like lactic acid, which is not a “toxin”—out of muscles and into the bloodstream for elimination. This idea isn’t supported by sound scientific evidence. A healthy body already removes waste efficiently through the liver and kidneys without the need for a massage.

The persistence of the myth likely stems from a mix of outdated physiology, misinterpreted soreness after massage, and a desire to offer clients a dramatic-sounding benefit.

What to expect in a deep tissue massage session

Before any massage, your therapist will have you fill out a health history intake form to determine if there are any contraindications for massage, provide a Health Insurance Portability and Accountability Act (HIPAA) statement to sign for privacy and also inform you of your rights and responsibilities. They will also explain techniques that will be used in the session, especially if it’s a bodywork style you haven’t received before.

Communication before, during, and after massage is key. During the intake before the session, you will be asked about your preferences and address any questions that you may have. Don’t be afraid to ask about what to expect before the session.

Massage therapists will often go over draping procedures, and clarify where they will work on. Only the area being worked on will be undraped in the session while all other areas remain covered. If adjustments need to be made throughout the session, your massage therapist would be more than happy to accommodate.

Deep tissue massage work may focus on the shoulders, chest, hips and gluteal muscles. Working on chest or gluteal muscles can be uncomfortable or a sensitive boundary for some clients. And so, the intake is an ideal time to ensure that there’s a clear understanding of which areas of the body will be worked on and which will not.

If you don’t like a certain pressue, you don’t have to wait until the therapist checks in to speak up about making changes.

Deep tissue massage precautions

Sessions should be rescheduled when you have a cold, flu, or any other contagious disease, even if you feel it is mild or negligible. Because massage cannot detoxify the body in any way, coming in sick for a massage not only can overtax the your already-compromised system but is also inconsiderate for the therapist’s health.

You should also avoid massage if under the influence of drugs or alcohol, including any prescribed drugs for pain.

In the case of sunburn, cuts, abrasions, varicosities, undiagnosed pain, or localized inflammations, it’s possible to receive massage while avoiding touching these areas.

Massage should also be avoided if you:

• Develop any unusual skin conditions,
• Had a recent accident
• Had a recent surgery
• Have a sudden onset of unusual symptoms (e.g. visual impairment, intense headaches)

If you have an underlying chronic health condition, always seek the guidance of a medical professional or treating physician. Unless a massage therapist has a qualifying medical degree, they’re not legally able to diagnose any conditions you may have.

If you’re pregnant, consult your physician before booking a massage session. Unless it’s a high-risk case, there’s no reason that an expecting mom needs to avoid massage therapy during pregnancy.

Much like other myths in massage therapy, there are misconceptions whether or not it’s safe for pregnant women to receive massage. Massage cannot cause miscarriage or induce labor, and these myths have come from both fear, causal misattribution, and unsubstantiated claims.

“If a woman is not restricted from normal activities due to other complications, it is not necessary to deny her massage during her first or any trimester.” ~ Alice Sanvito, LMT

How to find the best deep tissue massage near you

Finding a massage therapist who is evidence-informed and offers deep tissue massage can be a bit challenging, depending on where you live.

Getting referrals is a worthwhile resource if you have a particular condition you would like treated. Licensed medical professionals often have massage therapy resources that specialize in specific conditions.

Massage organizations, such as the American Massage Therapy Association or Associated Bodywork and Massage Professionals, often have member resources, and they usually check the qualifications of the therapists listed on their sites. The U.S. federal government does not regulate massage therapy. It allows each state to regulate massage per their own health department regulations.

While there are a few states that don’t require formal training for massage, you shouldlook for therapists who have formal training in massage and will provide care in a safe and effective manner. This ensures that you’re receiving care by a therapist who is knowledgeable pathology, anatomy, massage ethics, and regulations.

Other checklists include:

• Make sure the therapists have applicable licensure or certifications based on the area you’re in,
• Check if they hold appropriate massage liability insurance.
• Call and ask questions that may not be offered on the therapist’s website. Sample questions include how many years they have been in practice, their practice philosophy and specialties, and where did they get their training.