Patients often seek massage therapy for pain and stress relief, yet they often receive outdated information about pain that sometimes make them feel more fearful about their body.
Recently, I had a client who told me that not only his right shoulder felt “tight” and sometimes painful when he retracts it, he also “could not retract” as much as his left side could. Although I could not find any significant differences between both sides (he could almost pinch a ping-pong ball with his scapulae), he said that his right shoulder felt like it doesn’t want to move back. Any attempt to retract further back elicits a numbing pain in his shoulder near the AC joint. He blamed his desk job is causing his tightness and pain where he used the mouse a lot.
Having ruled out injuries and pathologies, instead of telling him that his tightness and pain comes from “muscle knots” or one side of his pelvis is higher than the other or another biomechanical “fault,” I simply told him, “You seem fine for now and I’ll check in with you during the session. Afterwards, we’ll see how you feel. Cool?”
He agreed and we proceeded to the session. I did not mention anything about how tight he was or say stuff that I would have said ten years ago when I believed posture and structural “abnormalities” have a direct causality to pain. He already came in to see me with physical and emotional discomfort that has been nagging him for many months. I don’t need to drip kerosene to his fire.
Most of massage therapy education is still heavy on “the issue is in the tissue” paradigm, part of the biomedical and biomechanical lens that many other healthcare professionals also adopt. Therefore, it is no surprise that most of our bias weighs on muscles, bones, joints, and more muscles. However, nearly five centuries of pain research since the time of René Descartes and Paré Ambroise have shown that most of our pain experience is highly influenced by the nervous system, including the brain.
As technology and the understanding of human physiology improved in the 19th century and onward, we later found that our immune (1,2) and endocrine systems also play a critical role in pain, (3,4) including how the menstrual cycle can affect women’s pain experience in the brain. (5) Environmental factors, such as culture, (6) family (7, 8), and socioeconomics (9) can also influence someone’s pain. Even the things you say to clients or patients can influence how they feel during and after a treatment. (10)
The deeper you dig in the rabbit hole of the biopsychosocial framework of pain and general health, you start to question whether the things you had learned in and outside of of massage or physiotherapy school are accurate and up-to-date. But why should you care? Would improving your understanding of pain science change the way you already work with clients/patients?
1. Ethics: your clients and patients deserve it
The College of Massage Therapy of Ontario (CMTO) in Canada states in the code of ethic’s preface statement, “as regulated health professionals, we have made a promise to society to accept the responsibility and maintain the trust with which we have been invested. It lays out clearly the massage therapy profession’s values and explains what they are in terms of what we ought to do in order to protect and promote the public good, and what we must avoid doing in order to prevent harm to the public.”
Massage New Zealand also have their own code of ethics, which has similar core values as CMTO including protecting the public from malpractice and harm and staying within scope of practice. You don’t want a massage therapist giving out nutrition or dental health advice if they are not a dietitian or dentist.
Thus, understanding how pain works would provide your clients/patients with the best information about why they might be experiencing a particularly type of pain. For example, in some cases, low back tightness and pain may likely be a result of a highly sensitive nervous system that is protecting your back from potential harm, due to central sensitization. (11) Thus, any therapist who try to “muscle” their way in to “release” the muscle would likely cause more pain and long-term hyperalgesia. If the client/patient does not have any pathologies or injuries that may contribute to the pain, a gentler approach to hands-on treatment—combined with attentive care and touch—may be a better way to treat such conditions. This would protect the client from nocebic messages about their body and unnecessary aggressive work that may likely cause hematoma (12) or similar issues.
Also, there is some evidence that providing clients/patients with pain education based on current science can provide some short-term low back pain relief. (13) Having this knowledge boost may enhance the pain-relief symptoms of your clients’ or patients’ visit. Of course, this may not work for everyone, but it is better than providing outdated ideas about pain that may make them more tense and worried after their session.
2. Professionalism: it is your obligation
Accountants, car mechanics, and criminal law attorneys often need to update their knowledge about their line of work regularly, as do most healthcare professionals, like surgeons, dentists, and nurses. So why shouldn’t massage therapists and other manual therapists do the same?
Medical knowledge—from the human genome to mental health—currently undergoes rapid changes and knowledge expansion that has never happened prior to the Industrial Revolution. (14) Dr. Peter Densen, who teaches internal medicine at the University of Iowa, stated in a 2011 paper that medical education and training does not reflect well on what newly graduated physicians would face in the real world. (15)
He also wrote, “It is estimated that the doubling time of medical knowledge in 1950 was 50 years; in 1980, 7 years; and in 2010, 3.5 years. In 2020 it is projected to be 0.2 years—just 73 days. Students who began medical school in the autumn of 2010 will experience approximately three doublings in knowledge by the time they complete the minimum length of training (7 years) needed to practice medicine. Students who graduate in 2020 will experience four doublings in knowledge. What was learned in the first 3 years of medical school will be just 6% of what is known at the end of the decade from 2010 to 2020.
“Knowledge is expanding faster than our ability to assimilate and apply it effectively; and this is as true in education and patient care as it is in research. Clearly, simply adding more material and or time to the curriculum will not be an effective coping strategy—fundamental change has become an imperative.”
Although massage education and training are about one to two years in most countries, why would they be much different in terms of knowledge updates?
With such rapid changes in this field of knowledge alone, where can you start? Continuing education courses in massage and other manual therapies would be a good starting point. Choose courses that are not only aligned with the basic sciences (e.g. human physiology, psychology, biomechanics), but also are updated to recent research and are open to questions. If you cannot afford a course yet, there are plenty of reliable online resources that are up-to-date in pain research and massage practices, such as PainScience.com, Massage Therapist Development Centre, Cor-Kinetic, Pinpoint Bodywork, and Body In Mind (although the website is currently defunct since the team has moved on to bigger and better things).
3. Sharing the same language with other healthcare professionals
Sharing the common and current understanding and language of pain could give you an edge in working with other healthcare professionals, if you are working with a medical team. If they are up-to-date in the biopsychosocial framework of pain and health, then you are in luck. You would likely have little trouble communicating with other team members, and they may likely update their knowledge and be flexible with their treatments should new evidence indicates something different, more efficacious, or safer. (This reminds me of my grade school years when nurses used mercury-filled thermometers to take my body temperature by sticking it beneath my tongue. Nowadays, they use an ear thermometer instead. Quicker and less risky!)
Even if you are updated with how pain works, this would probably not change your hands-on work much. Instead, it would change how you communicate with your clients/patients, such as the questions you ask during an assessment and the words you choose if they ask you what is going on with them. You might feel some discomfort in knowing what you had believed to be incorrect, but that feeling would pass like a minor dry skin itch. The reward of knowing a little more far outweighs the benefits of holding on to old ideas.
Remember, your clients or patients would be glad that you are still learning, even if it means taking time away from your practice for a few days or a week to attend a pain science conference to keep yourself updated and provide better service to them. They look to you as an expert—possibly the only trustworthy expert in aches and pains.
“Do not introduce yet another pathology into the possibilities of what might be wrong. Try to be less wrong in the words you speak and write. Realize your training was under the bias of the teacher and the modality’s inherited narrative reinforced by your peer group and further reinforced by the positive outcome you saw as a result of acting on the beliefs that you were taught.” ~ Walt Frtiz, PT
1. Ren K, Dubner R. Interactions between the immune and nervous systems in pain. Nat Med. 2010;16(11):1267–1276. doi:10.1038/nm.2234
2. Pinho-Ribeiro FA, Verri WA Jr, Chiu IM. Nociceptor Sensory Neuron-Immune Interactions in Pain and Inflammation. Trends Immunol. 2017;38(1):5–19. doi:10.1016/j.it.2016.10.001
3. Tennant F. The physiologic effects of pain on the endocrine system. Pain Ther. 2013;2(2):75–86. doi:10.1007/s40122-013-0015-x
4. Vincent K, Tracey I. Hormones and their Interaction with the Pain Experience. Rev Pain. 2008;2(2):20–24. doi:10.1177/204946370800200206
5. Veldhuijzen DS, Keaser ML, Traub DS, Zhuo J, Gullapalli RP, Greenspan JD. The role of circulating sex hormones in menstrual cycle-dependent modulation of pain-related brain activation. Pain. 2013;154(4):548–559. doi:10.1016/j.pain.2012.12.019
6. Peacock S, Patel S. Cultural Influences on Pain. Rev Pain. 2008;1(2):6–9. doi:10.1177/204946370800100203
7. Palermo TM, Eccleston C. Parents of children and adolescents with chronic pain. Pain. 2009;146(1-2):15–17. doi:10.1016/j.pain.2009.05.009
8. Noel M, Beals-Erickson SE, Law EF, Alberts NM, Palermo TM. Characterizing the Pain Narratives of Parents of Youth With Chronic Pain. Clin J Pain. 2016;32(10):849–858. doi:10.1097/AJP.0000000000000346
9. Dorner TE, Muckenhuber J, Stronegger WJ, Ràsky E, Gustorff B, Freidl W. The impact of socio-economic status on pain and the perception of disability due to pain. Eur J Pain. 2011 Jan;15(1):103-9. doi: 10.1016/j.ejpain.2010.05.013. Epub 2010 Jun 16.
10. Klinger R, Blasini M, Schmitz J, Colloca L. Nocebo effects in clinical studies: hints for pain therapy. Pain Rep. 2017;2(2):e586. doi:10.1097/PR9.0000000000000586
11. Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain. 2009;10(9):895–926. doi:10.1016/j.jpain.2009.06.012
12. Sharma I, Joseph D, Kirton O. Traumatic complications of inpatient massage therapy: Case report and literature review. Trauma Case Rep. 2018;18:1–4. Published 2018 Nov 16. doi:10.1016/j.tcr.2018.11.003
13. Wood L, Hendrick PA. A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: Short-and long-term outcomes of pain and disability. Eur J Pain. 2019 Feb;23(2):234-249. doi: 10.1002/ejp.1314. Epub 2018 Oct 14.
14. Murrell D. What is modern medicine? Medical News Today. 2018 Oct 31.
15. Densen P. Challenges and opportunities facing medical education. Trans Am Clin Climatol Assoc. 2011;122:48–58.
A native of San Diego for nearly 40 years, Nick Ng is an editor of Massage & Fitness Magazine, an online publication for manual therapists and the public who want to explore the science behind touch, pain, and exercise, and how to apply that in their hands-on practice or daily lives.
An alumni from San Diego State University with a B.A. in Graphic Communications, Nick also completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014.
When he is not writing or reading, you would likely find him weightlifting at the gym, salsa dancing, or exploring new areas to walk and eat around Southern California.